People with health insurance pay less money out of pocket for crucial healthcare services than those who are uninsured, but with so many health insurance options, choosing the right health insurance plan can feel overwhelming. Everyone’s situation is different, so it’s critical to evaluate your options carefully to ensure you enroll in a plan that will provide the coverage you need.
When shopping for health insurance, it’s important to consider your budget, your current and future healthcare needs, and the coverage and network offered by the plan. Learn more about the most important things to consider when comparing health insurance plans.
Narrow Down the Type of Health Insurance You Need
Depending on your situation and projected healthcare needs, the best type of health insurance for you may differ from the best type for someone else. Families with young children, for example, may attend many more regularly scheduled visits than healthy adults without children in the household. Likewise, a healthy young person may not need the same coverage as someone with a pre-existing condition that requires consistent medical care.
All health plans on the Health Insurance Marketplace provide “minimum essential coverage” and meet requirements included with the Affordable Care Act. These plans provide coverage for 10 essential health benefits:
- Ambulatory patient services, which is any care that does not involve a hospital stay
- Emergency services, which is treatment for a life-threatening condition
- Hospitalization, which is care provided in a hospital setting
- Maternity and newborn care, including prenatal care and check-ups
- Mental health and substance abuse care, including psychotherapy and counseling
- Prescription medication
- Rehabilitative and habilitative care, which are services that help improve lost skills for day-to-day living due to injury or illness
- Laboratory services, including bloodwork and screenings
- Preventative and wellness care and chronic disease management
- Pediatric care, including dental and vision care
Every health marketplace plan has copayments, deductibles, and other costs, as well as network limitations and care management expectations. Learn how each type differs to better shop for health insurance.
Common Health Insurance Types at a Glance
| PPO | HMO | EPO | POS | |
|---|---|---|---|---|
| Primary care physician | No | Yes | No | Yes |
| Out-of-network care | Yes, partially covered | No | Medical emergencies only | Yes, with limitations |
| Pre-approval for medical services | Yes | Yes | Yes | Yes |
Preferred Provider Organization (PPO)
PPOs are one of the most popular and common types of health plans available, although they tend to be more expensive than HMOs. With many PPOs, you aren’t required to have a designated primary care physician, although you may want one to help provide continuity in care. Having a primary care physician may also help save time, as they can often provide basic care virtually or over the phone instead of requiring an in-person visit since they are familiar with you and have easy access to your medical records.
PPOs also provide the largest network size, but even if you opt for out-of-network care, it may be partially covered, unlike most other health insurance options. In addition, specialists and procedures do not typically require a referral.
Health Maintenance Organization (HMO)
HMOs tend to be budget-friendly because the network of healthcare professionals participating in the plan is typically smaller than other health insurance options. An HMO’s focus on prevention and wellness may also help contribute to its lower premium price. HMOs achieve savings in part by encouraging less expensive care, such as home health visits and ambulatory care, which may help reduce expensive hospital visits.
If you choose an HMO, you’ll also select a primary care doctor from within the plan’s network of providers. This primary care doctor will be who you see for all regular checkups and basic ailments and injuries. To see a specialist, who has special medical training that allows them to diagnose and treat conditions and diseases that a primary care doctor may not have the expertise to handle, a referral from your primary care doctor is needed.
Those seeking out-of-network care may not be covered except in emergencies, such as severe accidents requiring life-saving care, cardiac arrest, or other unavoidable situations where getting care is a matter of life or death.
Exclusive Provider Organization (EPO)
An EPO combines the characteristics of PPO and HMO plans. Like an HMO, an EPO often requires a designated primary care physician and out-of-network coverage is provided for medical emergencies only. The network of doctors is also local. But like a PPO, EPOs do not typically require a referral from a primary care physician to see a specialist.
EPO plans generally have lower monthly insurance premiums, but also may require higher out-of-pocket payments for services before the health plan starts paying a portion of your healthcare costs.
Point-of-Service (POS)
This type of managed care plan combines some attributes of PPO and HMO plans. Like HMOs, POS plans require you to choose an in-network physician as a primary care provider, and you must get a referral from your primary care provider to see a specialist if you want the plan to cover those costs. But like PPOs, POS plans allow you to see healthcare providers outside the plan’s network at a higher out-of-pocket cost.
POS premiums typically fall between the lower-cost HMO and more expensive PPO plans. POS plans may also offer nationwide coverage, which may be preferable if you travel frequently.
Determine Your Health Insurance Budget
The various components of your health insurance plan work together to influence the amount of money you pay for healthcare. For example, if you pay higher copays and have a higher deductible, your plan’s premium may be lower. When estimating your potential healthcare costs, it’s important to consider your current health status, including the level of care you currently require and whether you have ongoing or recurring health challenges.
Premiums
Your healthcare premiums are monthly charges that stay the same throughout the year. You must pay your health insurance premiums to keep your coverage active, even if you do not seek medical care. Healthcare plans offering more coverage and fewer out-of-pocket costs typically have higher premiums, so those who are relatively healthy and rarely need medical attention may save on their recurring premiums by electing a plan with higher out-of-pocket costs.
Deductibles
The deductible is an annual amount that you must meet before your insurance kicks in to help cover the costs of your healthcare. For example, you may have a $4,000 deductible for your family health insurance plan. This means you must pay $4,000 for your own healthcare before the plan starts picking up a portion of your medical costs. Copays typically do not count towards your deductible’s balance, but all other covered payments you make for healthcare do.
Because this acts as a cost you must pay out of pocket before your insurance chips in, healthcare plans with higher deductibles tend to have lower premiums, while plans with lower deductibles tend to have higher premiums to help offset the potential costs. If you need frequent care, a lower deductible may be a better option so that your health insurance can kick in sooner to help pay.
Copays
Copays are the flat fee you pay each time you or someone covered under your health insurance plan receives medical care or fills a prescription. These payments do not typically count toward your deductible. Depending on how your plan is structured, you may pay a copay and a deductible before your insurance covers any medical bills. Your copay amounts may differ depending on which type of healthcare you seek. For example, you may pay a higher copay amount to see a specialist than you would to see your primary care doctor.
Coinsurance
Coinsurance is the percentage of the total medical bill you pay after you meet your deductible and before you’ve reached your out-of-pocket maximum. For example, if your coinsurance is 20%, your health insurance may cover the remaining 80% of your bills after you’ve paid enough money toward your medical bills to satisfy your deductible.
Out-of-Pocket Maximum
Your out-of-pocket maximum is the maximum amount of money you pay during the year for covered healthcare services before your healthcare plan starts paying 100% of your medical bills. The Affordable Care Act (ACA) determines the maximum amount of money you’ll pay, depending on whether you have family or individual healthcare coverage. Any money you spend on healthcare services not covered by your health plan does not count toward your out-of-pocket maximum.
Find Your Health Insurance Options
You can choose to get health insurance coverage through an ACA-approved plan for individuals and families or through your employer or your spouse’s employer. You may also be eligible to receive healthcare coverage through Medicaid or Medicare. A health insurance agent or health benefits expert can help you navigate which options make the most sense for you.
Employer-sponsored Group Health Insurance
If you or your spouse are eligible for employer-sponsored group health insurance, you may be able to get the coverage you need and take advantage of lower rates. In employer-sponsored plans, often offered as an employee benefit, the employer pays a portion of their employees’ group health insurance premiums, making this an affordable way to get health insurance for many people.
However, with an employer-sponsored group health plan, your options may be limited to 2 or 3 plan options, which are usually HMOs, EPOs, or PPOs. In addition, employer-sponsored plans remain with the employer so if you or your spouse leave the employer, you’ll lose your healthcare coverage unless you choose to pay 100% of the premiums as well as administrative fees going forward. Even then, you can usually only keep coverage for up to 18 months, according to federal COBRA laws.
Individual and Family Health Insurance
ACA-approved individual and family health insurance plans are available for those who are not enrolled in Medicare, Medicaid, or a job-based insurance plan. These plans are typically PPOs, EPOs, and HMOs.
To enroll in an ACA-approved plan, you must apply and choose a policy during an open enrollment period, which typically occurs between November and January of the following year, depending on your state of residence. This period is open right now for most states. You may also be able to enroll in an ACA-approved plan outside of the open enrollment period if you qualify for a special enrollment period (SEP).
ACA plan options are available on the Health Insurance Marketplace, though some states have their own state-based exchange (SBE) where insurers offer approved policies. ACA plans have various tiers, named after metals:bronze, silver, gold, and platinum. Each plan provides coverage for the same services but may provide coverage for more or less of the total cost of care, which you may see reflected in the plan’s monthly premiums. For example, health plans offering lower out-of-pocket costs may have higher premiums.
Bronze and catastrophic plans usually have the least expensive premiums. Silver plans have average premiums and out-of-pocket costs. Gold and platinum plans have the highest monthly premiums, but also provide lower out-of-pocket maximums and deductibles.
Medicare
Medicare is government-provided healthcare designed for people over the age of 65 and those living with certain disabilities, ALS, or end-stage renal disease (ESRD). Original Medicare consists of Parts A and B. Those who delay enrollment in Medicare Parts A or B may have to pay late enrollment fees. Many people have premium-free Part A, but all Medicare beneficiaries must pay a Part B premium, even if they enroll in a Medicare Advantage plan.
Medicare Advantage plans, also known as Medicare Part C or MA plans, are offered by Medicare-approved private insurers as an alternative to Original Medicare. All MA plans must offer at least the same benefits as Original Medicare, and many also provide prescription drug coverage, commonly called Medicare Part D. With Medicare Advantage plans, you’ll see providers in the plan’s network, unlike with Original Medicare where you may seek care from any facility or provider who accepts Medicare. Depending on the plan, there may also be coverage for non-emergency out-of-network services, but your total out-of-pocket costs for covered services are limited each year.
Another Medicare option, Medicare supplement insurance (or Medigap), is offered by private insurers as secondary insurance to help cover the out-of-pocket healthcare costs associated with Original Medicare, such as coinsurance costs. Medigap plans are largely standardized, but may have state-specific regulations.
Medicaid
Medicaid provides access to crucial healthcare services for millions of low-income children, adults, and elderly people. You can apply with your state Medicaid agency or through the Health Insurance Marketplace. Eligibility requirements vary by state and may depend on your family size, whether you or a member of your family has a disability, the ages of people applying, family income, and other factors. Check with your state’s Medicaid office for details about the application process.
Medicaid typically covers regular doctor visits, diagnostic tests, and other services that are usually covered by any other health insurance plan. Depending on the state’s rules, those with Medicaid coverage may also receive dental care, screening services, behavioral health services, prescription drug coverage, and access to vision care services.
Get Policy Details and Quotes to Compare
Each health plan, whether it’s administered by the government or a private insurance company, has its own application process and rules for eligibility. You may need to provide basic identifying information about the people you’d like to include in the plan’s coverage, such as their full legal name, date of birth, physical address, and health status.
As you shop for health insurance plans, a health insurance agent can help you get quotes for health insurance policies that may best meet your needs from reliable health insurance companies. Your health insurance plan quotes may include a summary of benefits to give you an idea of your potential total cost of care, including premiums, copays, and deductibles, so you can easily compare potential costs. In addition, if you prefer to use certain doctors or visit a specific hospital, it may be necessary to exclude plans that restrict your access to covered healthcare services to in-network providers that exclude your preferred practitioners.
To make it easier to compare plans, consider creating a grid like the one below comparing these features so you can weigh the aspects that are most important to you.
| Policy Details | Policy A | Policy B | Policy C |
|---|---|---|---|
| Premium Quote | |||
| Copay for general visit | |||
| Copay for specialist visit | |||
| Deductible | |||
| Coinsurance rate | |||
| Out of pocket maximum | |||
| Etc. |
Make Your Selection and Enroll
After you compare health insurance plans and evaluate quotes, your agent can assist you with enrolling in a plan. For those joining a Marketplace plan, the Open Enrollment Period is currently active, running from November 1st until January 15th. Once you enroll, your coverage will specify a start date, and you’ll soon receive your insurance cards digitally or by mail. You’ll also typically be able to set up an online account with your provider, where you can track your claims, deductible, and more.