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Before Buying Health Insurance

Shopping for health insurance can feel overwhelming. Use these six questions as a general starting point to think through your needs and help you select a plan for you and your family. Health insurance plans may differ significantly in costs and benefits. Consider scheduling an appointment with one of our certified professionals who can walk you through the process. Get connected to someone in your area.

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1. How often do I need care?

Consider your past and future medical bills. If you are healthy and don’t expect to need many costly medical services throughout the year, then a Bronze plan – typically with the lowest premiums and highest costs for care – might be a good fit for you. However, if you or your family have a medical condition or are planning to have any surgeries, then a Gold plan that pays more of your medical costs (and has a higher monthly premium) might cost you less overall. Learn more about the coverage levels (or metal tiers).

2. What services do I need?

Write down what medical services you and your family routinely use. For each plan you are considering, read the Summary of Benefits and Coverage (SBC) to make sure they are covered. Reminder: Preventive services – such as an annual check-up or a flu shot – are usually free, when delivered by an in-network provider.

3. How much can I afford?

Think beyond the monthly premium amount and imagine what your costs might look like throughout the year. Consider the deductible – how much could you afford to pay upfront, in the case of a bad accident or serious illness, before your insurance starts to help you pay? Then, once the insurance kicks in, what is the coinsurance – the percentage of the bill you will have to pay? What about prescriptions and doctor visits – do you have a copay (fixed amount) or will you pay the full cost until the deductible is met? What is the out-of-pocket maximum? The most you’d ever have to pay for covered services and prescriptions in a plan year, not including your monthly premium. Learn more about the key elements of a health insurance plan that determine how much you pay.

4. Where do I like to go for care?

If you have specific doctors, hospitals and pharmacies that you prefer to use, make sure they are in-network (part of the provider network) for the plan you are considering. Most plans (HMOs and EPOs) won’t pay anything if you go out-of-network (and those costs won’t count towards your deductible or out-of-pocket maximum).  Because doctors can change insurance networks frequently, we recommend contacting the health insurance company to confirm that your doctor is covered by a plan before you buy.

Did You Know? Networks change from plan to plan. If your doctor is in-network (covered) by one health insurance company’s plan, do NOT assume that he/she is covered by ALL plans offered by that insurance company.

5. Are my medications covered?

Not all health plans cover all prescriptions. Each insurance company has a list of prescriptions they cover, called a formulary or drug list, on their website. These lists often split drugs into ‘tiers’ or categories, which determine your share of the costs. While some plans have a copay for prescriptions, a fixed amount that starts right away, other plans require you to pay the full cost until you hit a prescription deductible (if there is one) or your overall plan deductible (which is more common).

Generics can save you money: There may be multiple brand and generic medications that address the same health issue. Generic options cost less than the brand name drugs and are typically covered by a larger number of health plans. Ask your doctor if a generic is right for you.

6. What matters to me the most?

All health insurance plans must cover a specific list of Essential Health Benefits including hospital stays, ER care, outpatient care, maternity and newborn care, prescription drugs, free preventive tests and services, mental health and substance use disorder services, rehabilitative services and devices, lab tests, chronic disease management, and pediatric services including dental and vision care for children. Beyond that, plans can vary greatly.

Here’s a list of common trade-offs between plans that impact how much you will pay:

  • Big vs. small provider network (doctors, hospitals, pharmacies, etc. that are covered by that plan)
  • 20% to 50% coinsurance (percentage of the bill that you pay)
  • Copay right away for prescriptions vs. needing to pay the full amount until the deductible is met
  • Need a referral to see a specialist or not
  • Additional services beyond the minimum required that may be important to you
  • Low premium with higher costs when you receive care vs. higher premium with lower costs when you receive care

Coverage levels (or metal tiers)

Health plans are arranged into three levels to help you narrow your options based on your budget and health needs. The lower the premium, the higher the cost for care, and vice versa. Learn more about coverage levels.


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