Understanding your health plan choices

As you transition to civilian life, shopping for health care can be confusing. But it’s an important and necessary decision. You don’t want to pay too much for care you don’t need or too little for care that doesn’t protect you. You want to make the right choice for you and your family’s health.

Kaiser Permanente is here to help make this important decision an easy one. We designed this page as your complete resource for health care and coverage, with everything you need to know.

Learn more about how your VA works with other health insurance

Watch for a quick overview of how a health care plan works, key health care terminology, and some considerations for choosing a plan.

How does health insurance work?

Medical services are often very expensive, which can make it hard to afford regular care and budget for emergencies. Instead, you can make small upfront payments for health insurance, which will then cover a significant portion of your medical expenses when necessary.

Health insurance has two key elements: health care and health coverage.

1. Health care

Everyone gets sick or injured occasionally. Health care is the actual services provided by medical professionals who diagnose, treat, and help prevent medical issues. These services include:

Doctor appointments
Hospital stays (surgery / treatment)
Emergency room visits
X-rays
Laboratory tests
Prescription drugs
Preventive care
Well-baby visits
Well-woman visits
Immunizations
Screenings

2. Health coverage

Health insurance is a contract between you and an insurer, known as health care coverage or your health care policy. The contract stipulates:

You pay a monthly premium to your insurer in exchange for health coverage for medical services.
Your insurer pays for a portion of your medical services.

Quality health insurance gives you:

Peace of mind

Life is unpredictable. When you have health insurance, you're more in control. You can rest easy knowing that you have coverage for the care you need if your health is ever at risk.

Financial protection

Without insurance, your only choice is to go to the emergency room—which can be expensive. High medical bills can wipe out savings and even lead to bankruptcy. Insurance helps protect you financially if you have a serious illness or injury that requires extensive care by paying the costs.

Care when you need it

You can see a doctor when you’re sick or just need preventive care. You don’t need to ignore symptoms or hope they’ll go away. You can get treated before things get worse.

Better health

Because you’re paying for health insurance, you’re more likely to use it. Seeing your doctor regularly will enable you to take advantage of preventive care, to help catch minor symptoms before they become problems. Screenings, like mammograms and cholesterol level tests, can identify problems early—when they’re easier to treat.

Health care terminology

Premium

A fixed monthly payment for coverage, regardless of how many medical services you receive. You also pay an out-of-pocket cost for most services, but your coverage reduces the overall price.

Deductible

A large upfront payment for coverage. You pay the full cost of medical services until you reach this amount, after which your health insurance begins contributing. You usually still pay a copay or coinsurance for each service.

Copay

A fixed out-of-pocket payment for certain services covered by your health plan. Copays may apply whether or not you’ve met your deductible.

Coinsurance

A variable out-of-pocket payment for certain services covered by your health plan, dependent on the price of the service. Coinsurance may apply whether or not you’ve met your deductible.

Unlike copays, which are flat payments, coinsurance payments are a percentage of the price of the service. Your plan may have copays, coinsurance, or both.

Out-of-pocket maximum

The maximum amount per year that you can pay for services out of pocket. After reaching this amount, your health plan pays the full cost of most covered services. You must still pay your monthly premium, and possibly copays or coinsurance depending on your plan.

How copays work

You get a routine check-up from your doctor.

The total cost of the visit is $100.

Your insurance plan covers $80.

You pay the difference: $20.

Cost tiers for health plans

Health plans on the healthcare.gov exchange fall under four tiers based on how the insured person and the health plan divide the costs.

BRONZE

Lowest monthly premium

Highest deductible

Highest out-of-pocket costs

A good choice for healthy people who rarely access care and want low-cost coverage for when they occasionally get sick or injured.

SILVER

Moderate monthly premium

Moderate deductible

Moderate out-of-pocket costs

A good choice for generally healthy people who are willing to pay slightly more upfront for lower out-of-pocket costs.

GOLD

Higher monthly premium

Lower deductible

Lower out-of-pocket costs

A good choice for people who regularly access care or who have dependents.

PLATINUM

Highest monthly premium

Lowest deductible

Lowest out-of-pocket costs

A good choice for people with chronic health issues who frequently access care, especially specialty care and recurring tests and prescriptions.

HMO vs. PPO — What's the difference?

Health maintenance organization (HMO)

A network of hospitals, doctors, and other health care providers who agree to provide medical services within the network in exchange for a certain payment rate. With few exceptions, you must access care within the HMO network.

Preferred provider organization (PPO)

A health plan that contracts with hospitals, doctors, and other health care providers to create a flexible network of participating providers. You may access care inside or outside the network. In-network care is usually priced similarly to an HMO, while out-of-network care is more expensive in exchange for flexibility.

HMO vs. PPO — How do they compare?

HMO

PPO

Overall cost

Generally lower monthly premiums and out-of-pocket costs.

Generally higher monthly premiums and out-of-pocket costs. You usually need to pay the full cost of medical services until you reach your plan deductible, after which your health insurance begins contributing.

Payment structure

You pay a monthly premium. Your doctor earns a salary instead of being paid per service.

You pay a fee for each service.

Management

You select a primary care physician who manages your care within the HMO network.

You select your own primary care physician from inside or outside the network and manage your own care, which includes carrying information, test results, etc. from doctor to doctor.

Provider access

You can only see contracted providers inside the HMO network, except in emergencies.

You can see providers inside or outside the PPO network. Your costs are usually lower inside the network.

Referrals

You may need a referral from your in-network primary care physician to see specialists.

No referral required to see specialists.

Why Kaiser Permanente

Now that you understand health insurance better, we’d like to explain why we’re the right choice for you. Kaiser Permanente is an alliance between Kaiser Foundation Health Plans and their respective Permanente Medical Groups — in other words, an alliance between health care and coverage. We combine them into our complete integrated care system, which operates more cohesively and efficiently than traditional health insurance.

In the traditional PPO model, health insurance and health care are separate entities with competing agendas. Providers charge per service and profit from you accessing as many services as possible.

Our HMO-based system puts care and coverage on the same team, with one common goal: your health. Your doctor is paid a salary to care for you, regardless of how many services you access, and you make decisions together without interference from an insurance company. This eliminates redundant and expensive services, frees you from having to manage your own care, and creates better health outcomes for you.

Healthy extras

The healthier you are, the lower your health care costs will be. When comparing health plans, look for tools and services that make it easy to access care and live healthier overall. Just consider what Kaiser Permanente’s health coverage includes at no extra cost:

Convenient care access

Our innovative suite of care access options allow you to get treated how when, and where you need it.

Healthy lifestyle programs

We offer personalized, online programs to help you create an action plan to reach your health goals.

Fitness deals

Stay active and fit with a variety of reduced rates on studios, gyms, fitness gear, and online classes — just for Kaiser Permanente members.

Self-care apps

Our wellness apps can help you navigate life’s challenges, improving your sleep, mood, relationships, and more for total health.

Personal wellness coaching

Get one-on-one guidance and support from a dedicated wellness coach who can help you set goals, stick to them, and, most importantly, see results.

Health care 101 resources

Please take advantage of this additional selection of articles to help build your knowledge of health care, so you can make an informed insurance decision.

Veteran Care