Picking healthcare coverage isn’t an easy task, but that doesn’t mean it has to be overwhelming. Yes, there’s a lot to account for -- unfamiliar terms, enrollment periods, tiers, and fees -- but it’s not impossible to figure out! In this guide, you can find terms, tips, and questions you should be asking. Keep reading to learn how to pick the best health insurance plan for your needs!
How To Pick The Best Health Insurance Plan: 5 Tips
There’s no one-size-fits-all when it comes to insurance. Picking the best plan for you is a lot easier when you know exactly what it is your family needs. Check out our tips, and as you shop for insurance, ask yourself the questions we’ve provided below.
1. Before You Begin, Get To Know The Common Plan Types
While shopping for insurance, you’re probably going to come across a lot of unfamiliar terminology. It’s a good idea to acquaint yourself with all of it, but the most important thing to learn is plan type. Here are common plan types:
HMOs, or Health Maintenance Organizations, are integrated care plans that limit which doctors and facilities you can see. If you are seen by a healthcare provider who is out of network, you’re responsible for the bill. As long as you’re in-network, however, costs are generally lower than other types of plans. If you really don’t think you’ll go outside the network, or if you prefer integrated care, an HMO might be right for you.
PPOs, or Preferred Provider Organizations, offer a great deal more freedom in who you can see. Costs for visits to out-of-network providers are generally lower, and you don’t need a referral to see them.
EPOs, or Exclusive Provider Organizations, are similar to HMOs in that they only cover in-network care, but their provider networks tend to be much more expansive. EPOs will typically have monthly premiums that are higher than an HMO but lower than a PPO.
POS, or Point of Service plans, are a hybrid of HMOs and PPOs. You will need referrals to see specialists like an HMO, but your coverage for out-of-network providers and facilities will be slightly better.
2. Get The Whole Picture On Expected Out-Of-Pocket Costs
Your health insurance costs involve more than just a monthly premium. Before you sign up for the plan with the cheapest monthly fee, make sure you look into the plan's deductible -- that's the amount you’re responsible for before coverage will kick in -- whether it has coinsurance, which is a percent of the bill you must pay during medical visits, and any copayments you may need to make when you visit a doctor or pick up a prescription.
As tempting as a lower premium is, it almost certainly means higher out-of-pocket costs.
Do you anticipate needing expensive medical care soon? Have an upcoming surgery? If so, you want to ensure you’ve maxed out on out-of-pocket costs as soon as possible, so that the rest of your medical bills are covered. Does the plan you’re looking at have a lower deductible? That will be better if you anticipate utilizing many services or having procedures done.
Are you having a baby? What sort of additional benefits does the plan provide? Is neonatal care included? These things are not guaranteed plan-to-plan, and deciding whether you want these benefits can affect the cost.
How do you want to split the costs of healthcare? The Healthcare Marketplace splits insurance plans into 4 “metal” categories reflecting how healthcare costs are split. Knowing what you want can help you quickly pick a category.
Many insurers offer tools to help you calculate your estimated total annual costs. Even if you’re shopping in the Marketplace, it’s worth visiting an insurer’s website to check for tools like this.
3. If You Need Prescriptions, Check The Plans’ Drug Formularies
If you’re already getting regular prescriptions for a particular medication, you should pull up the drug formulary for any plans you’re considering. A formulary is a list of generic and brand-name medications covered by a health plan.
You may find that a particular plan charges less for a prescription you’re already getting. For specialty medications, in particular, this could help you avoid reaching a plan’s out-of-pocket maximum.
How does this work? Insurance companies categorize medication into tiers, usually 1 through 4. Tier 1 medications are cheaper than tier 4 medications, but not all plans categorize all medications the same way. Your prescription may be in a higher tier on one plan and a lower tier on another.
4. Consider The Plans’ Provider Networks
The network is a list of providers and facilities that accept a particular insurance policy. Across the board, regardless of plan type, it's going to cost more to see a provider or visit a facility that is not in-network. This is an important consideration to make, especially if you've already got a primary care provider you prefer.
Most insurers allow you to search a database online to verify whether a medical provider or facility is in-network. If you're having trouble finding a tool like that on the insurance company's website, you can give them a call. Just make sure you are specific in naming the doctor you want to verify and the insurance policy you're considering purchasing!
Do you have a primary care physician you’d hate to part ways with? Is there a pediatrician who is just great with your kids? Maybe a particular hospital or practice is more convenient to your home than others in the area? Figure out whether those facilities or providers are in-network for a plan you’re considering. You may also find that an HMO plan is best for you.
Do you travel a lot? Are you planning on moving soon? Does the plan you’re looking at have a large pool of in-network providers? How much of the bill are you responsible for if you see someone who’s out-of-network? Is there an appeals process in the event of an emergency? If you’re traveling a lot, these are all important questions to ask. Take a look at PPO-type plans over HMOs.
Do you need to see many specialists? If you have an ongoing medical condition that necessitates seeing specialists, are they in-network? How easy is it to see specialists with a given insurance policy? Do you need referrals? Checking the costs on specialists can save you money.
5. When In Doubt, Get Help From An Expert
If you’re stumped, HealthCare.gov can put you in touch with someone in your area who is trained and certified to help individuals and small businesses sort through coverage options in the Marketplace. These agents and assisters, called navigators, provide their services free of charge, and are required to be unbiased in the help they provide.
Through HeathCare.gov’s Find Local Help tool, you can either search for agents, brokers, and assisters in your area directly or have one contact you. From there, either over the phone or in person, you can begin to explore what health insurance plans will work best for your needs.
How To Pick The Best Health Insurance Plan: What’s Next?
Now that you’ve got a good idea of how to pick the best health insurance plan, what next?
Check enrollment periods. Open enrollment for ACA insurance typically begins November 1st. With the ongoing COVID pandemic, enrollment periods have been extended, so keep checking on the end date for the current year. If you’re outside of open enrollment, you may qualify for a special enrollment period.
Set up a meeting with a Marketplace navigator if you feel like you’ll need the assistance. It’s good to be prepared!
Find your Marketplace. You can search through the federal website, HealthCare.gov. The federal website can also redirect you to state-level Marketplaces if one is available for you.
Before you jump into the Marketplace, paint a picture of what you and your family need. Make a list of the most important features and check each plan you view to see how many points on the list they check off. By keeping this guide handy as a reference, you can verify that you’ve covered everything, and with that, you’re all set to start shopping for insurance!