Underwriting: In most states they are all underwritten plans. That means that you or an individual family member can be declined based upon health history and sometimes other factors. Because of health history, the premium could be greater than the regular premium, or a specific medical condition could be excluded from coverage, depending on state law or the insurer.
In states where coverage is guaranteed for everyone, there is not much choice of insurers or plans and the cost tends to be higher. We find significant restrictions on underwriting in MA, ME, RI, NJ, NY, and VT.
PPO: When it comes to claims payment, most plans use a "PPO" (Preferred Provider Organization).
That means that an agreement was made with many, if not most, independent medical providers in your area to make claims payment more efficient. Those who agree are "in-network". Those who do not are "out-of-network".
For each medical procedure, the network agreement incorporates codes and pre-agreed payments. In-network providers file the claims, so usually you do not have to.
You can go to any health care provider with a PPO plan. Some are just "out-of-network".
Indemnity: There are also plans with no claims network, called "Indemnity". Since there is no claims network you will likely have to pay all the smaller bills first and then file the claims yourself.
The provider will probably file the claim for big bills because they fear that you may collect from the insurer and then not pay them. However, don't be surprised when there is a disagreement between the insurance company and the provider as to whether the charge is reasonable. If the insurer repeatedly allows itself to be taken advantage of, it may go out of business, so it needs to be vigilant and not overpay. Incredible as it sounds, the insurance company is not always to blame.
For the same out-of-pocket to you, Indemnity plans cost the insurance company more to operate. Consequently, you will be charged more in premium. All providers are, so to speak, "out-of-network". That is not only inefficient, but is also of no advantage. It does not increase the number of providers you can go to.
Because there is no advantage to the Indemnity plan, and it has the potential for more inconvenience, and it costs more, there does not seem to be any reason to buy one.
HMO: These plans are available in some areas.
"HMO" may mean either an organization that employs the physicians and owns facilities or it may mean that an insurance company has a special contract with independent providers. The contract may provide for contracted primary care providers to receive a flat amount per HMO member and it is up to the physician to provide appropriate care on that budget. Specialists may be available only by referral. However, there is a lot of variation.
The advantage you see may be in plans that have more copays instead of having to meet a deductible, more generous copays i.e., an office visit copay covers more items than a PPO office copay does, and more generous preventative wellness checkup coverage. There may be a copay for emergency room, for outpatient surgery, and for hospital admission, whereas in most PPO plans the deductible has to be met first and maybe coinsurance on top of that.
The disadvantage is always far less choice of medical providers and maybe referrals needed to see specialists if that is required by the plan.
Some consumers also do not like the concept of capitation where the primary care doctor is paid a flat amount per patient instead of a fee for each visit or treatment. The concern is that care may be compromised because more care does not result in more income.
Association Plans: There may be an exception somewhere, but you can expect most every so-called Association plan that you ever come across to amount to nothing more than underwritten Individual coverage.
Such plans do not have true "group rates", but some operators have used a filing of a plan under the umbrella of an association as a slick marketing ploy to lure the unwary or busy health insurance buyer into a complacent lack of making careful comparison of the over-priced "group plan".
Self-employed people are often telemarketed with this gimmick.