It isn’t easy choosing health insurance, whether your employer offers it or you’re buying it yourself. Larger employers tend to offer more than one plan, all with different premiums, copayments, benefits and deductibles. Use these tips to make sure you choose the right insurance for you and your family.
- Compare the Metals
- Consider Your Health
- Do the Math
- Look at Out-of-Pocket Costs
- Review the Provider List
- Read the List of Benefits
- Look at the Drug List
- Ask the Right Questions
- Check the Plan’s Quality
1. Compare the Metals
There are five levels of plans on the exchanges: bronze, silver, gold, platinum and catastrophic, all with different deductibles and coverage. The more expensive the metal, the more expensive the plan. Bronze, for instance, has the lowest premiums and covers 60% of medical costs. Platinum is the highest, covering 90% of medical costs.
Catastrophic coverage, available to people with certain hardship or affordability exemptions, has the lowest premiums but the highest deductibles. It also covers less than 60% of the cost of care. These plans are designed to protect you from the costs of major accidents or illnesses.
2. Consider Your Health
If you have one or more medical conditions that require ongoing care, such as diabetes or heart disease, you want a plan with a lower deductible and lower copayments. You’ll pay a higher premium, but your overall out-of-pocket costs may be lower.
3. Do the Math
People focus on the monthly premium, but you also need to look at the deductible. For instance, if the lowest premium is $150 a month for a plan with a $3,000 deductible, and another plan’s premium is $200 a month with a $1,500 deductible, you’re better off with the second plan if you anticipate needing more than $1,500 in medical care. Then your total annual cost for the premium and deductible comes to $3,900, a $900 savings over the “cheaper” plan.
4. Look at Out-of-Pocket Costs
The deductible is just one out-of-pocket expense; you also have copayments and coinsurance. The three together are your maximum out-of-pocket costs.
In 2023, the maximum out-of-pocket limit is $9,100 for an individual plan and $18,200 for a family plan.
5. Review the Provider List
Most health plans today have “in-network” providers. If you see those doctors and visit those hospitals, you pay less out of pocket than if you go outside the network. So if you want to keep your own doctor and go to a certain hospital, make sure they’re on the provider list.
6. Read the List of Benefits
All individual and small business plans have to cover preventative wellness, hospitalization, emergency services, lab tests, maternity and newborn care, mental health and substance abuse treatment, outpatient care (doctors and other services received outside the hospital), pediatric services (including dental and vision care), prescription drugs, preventive services, and rehabilitation services. Your employer’s plan, however, may differ, so be sure to read through the plan’s Evidence of Coverage.
7. Look at the Drug List
All plans have a formulary, a list of medications they cover and the copayment for each. If you take prescription medicine, check the list to see if your drug is on it and how much refills will cost. If your medication isn’t on the formulary list, you may have to pay for it in full.
8. Ask the Right Questions
Call the member services department of the health plan you’re considering or talk with someone in your human resources department and ask:
- Can I go to any doctor, hospital, clinic or pharmacy I choose? How much does it cost to go out of network?
- Are specialists such as eye doctors and dentists covered?
- Are pregnancy, psychiatric care, and physical therapy covered? What about home care or nursing home care?
- What is the most I’ll have to pay out of my own pocket to cover expenses?
- How are disputes about a bill or service handled?
9. Check the Plan’s Quality
Did you know you can check the quality of your plan with just a few clicks? The National Committee for Quality Assurance (NCQA) ranks health plans across the country based on their clinical performance, member satisfaction, and results from NCQA surveys.
Last updated: November 2021