When shopping for a health insurance plan, there are numerous aspects to consider ranging from your unique medical needs, to out-of-pocket costs, to health plan networks. If you feel overwhelmed by the breadth of the process, use this step-to-step guide to health insurance to help you choose the right health insurance plans for your needs.
How to Choose Health Insurance?
Choose a Marketplace
Evaluate Health Insurance Plans
If your employer provides a group health insurance plan, you do not necessarily need to use the insurance marketplaces or exchanges, unless you want to find an alternative health plan. It is worth knowing that the plans available on these marketplaces and exchanges are typically more expensive compared to employer-backed plans. This is because employers typically pay part of workers’ insurance premiums, and on average, the plans’ premiums are lower.
If your state has a marketplace, you can shop for a health plan there. Alternatively, you can use the federal marketplace, HealthCare.Gov, where you’ll need to enter your zip code to enroll in a health insurance plan. Once you enter your zip code, the site will direct you to your state’s exchange, if available.
When shopping for a plan, you need to familiarize yourself with the acronyms associated with health care plans. These include:
- Preferred provider organization (PPO)
- Health maintenance organization (HMO)
- Exclusive Provider Organization (EPO)
- Point of Service (POS)
Take note that the kind of policy that you choose will determine the doctors you can see and the costs you’ll pay out of pocket. Online marketplaces will show you the cost of a plan as well as its summary of benefits. Additionally, you’ll get to see a provider directory that lists the health providers that are part of the plan’s network. If you get your health insurance through your employer, you should ask for a summary of benefits from the benefits administrator at your workplace.
Comparing the Common Health Insurance Plans
- With an HMO (Health Maintenance Organization) insurance plan, you need to stay in-network, except when you need emergency treatment. You also need a primary care physician’s referral before visiting a specialist or scheduling a procedure. While your choice of providers is limited, your out-of-pocket costs are lower, and your primary doctor coordinates your care when you need a referral.
- With a PPO (Preferred Provider Organization) plan, you don’t have to settle for in-network care (although it’s typically cheaper), and you don’t need a referral before visiting a specialist or scheduling a procedure. However, your out-of-pocket costs are higher.
- With an EPO (Exclusive Provider Organization) plan, you have to stay in-network, except for emergencies, and you don’t need a referral before visiting a specialist or scheduling a procedure. The plan’s out-of-pocket costs are lower, but your choice of providers is limited.
- With a POS (Point of Service) plan, you don’t need to stay in-network, though health care is cheaper in-network, and you need referrals. The plan offers more provider options and when you need a referral, your primary doctor coordinates your care.
When evaluating the plans, you need to reflect on your and your family’s medical care needs.
Evaluate Health Plan Networks
Insurers contract lower rates from in-network providers. Your cost of medical care will be lower when you visit in-network clinics and doctors, and you’ll pay more when you visit out of network doctors with whom your insurer doesn’t have agreed-upon rates. An important factor to consider when choosing a plan is whether your preferred doctors take the plan. If you don’t have preferred doctors, you should opt for a plan with a wide network so that you have more options. If possible, eliminate plans that offer you limited provider options as well as those with no local in-network doctors.
When evaluating costs, you shouldn’t just look at the premiums. Instead, you should also consider other costs such as deductibles and copayments. Compare the costs that you’ll pay in each plan and opt for the most favorable. In order for you to make the comparison, you should familiarize yourself with insurance concepts and terms including:
- Out of pocket expenses – The portion of the medical cost that you’ll pay out of pocket when you receive healthcare
- Annual deductible – The amount you need to pay annually before your insurer starts paying their share of your health care costs.
- Copayment/Copay – This is a fixed amount you pay upfront whenever you receive care while your insurer pays the rest.
- Coinsurance – A percentage of your medical cost that you pay out-of-pocket. If a procedure costs $2,000 and your coinsurance is 20%, you’ll pay $400 and your insurer will pay the rest.
- Annual out-of-pocket maximum – The maximum amount you’ll pay out-of-pocket per year.
At this stage, you should look at the scope of services offered and how they relate to your needs. Some plans may offer better coverage for things like mental health care, fertility, or physical therapy while others may provide better coverage for emergencies. By comparing the benefits, you’ll be able to zero in on a plan that meets your family’s unique medical care needs.
Plan Network in Sync with Your Provider
It would be best to keep in mind that only in-network services and medicines are covered in a plan. In contrast, out-of-network services and medicines that require additional out-of-pocket expenses are not covered. Additionally, any out-of-pocket costs for your out-of-network healthcare provider or practice may not be included in your heal insurance plan’s maximum out-of-pocket expenses. Check to make sure that your preferred healthcare provider and pharmacist are included in your insurance plan.
Prescription Medicine Coverage
Your insurer has coverage for a list of medicines known as formulary. This list is divided into tiers that determine the amount of co-pay or coinsurance you have to pay. If a medicine is not on this list, it might not be covered in the insurance. As a result, you might have to go through a long process to obtain coverage. Please make a list of your medications and compare it with the formulary of your insurance plan to ensure your medicines are insured.
You might have to pay a certain sum of money out of your pocket before your coverage starts. For example, if your deductible amounts to $2000, your health insurance plan won’t pay for your medical expenses unless it exceeds $2000. The out-of-the-pocket costs can include specialist visits, prescriptions, and even procedure fees. Always check with your insurer to ensure that your plan has a single, combined deductible for pharmacy and medical services or a separate deductible for prescriptions.
Consult an Expert
Health insurance is inherently complex. Even after taking the above steps, you may still need the help of an insurance expert who’ll help you find a good health insurance plan for your needs.
By analyzing the costs, benefits, and health plan networks, you can find health insurance that suits your needs. To learn more about health insurance, contact our experts at J. Archer Insurance Group today. We are ready and able to walk you through the process of choosing the right insurance plan for your needs!