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It’s not just you — the world of private health insurance is really confusing. But enrolling in a plan is one of the most important things you can do to protect you and your family from expensive medical bills, and give you access to quality care.
But with so many options, how do you choose? Whether you’re picking a plan for the upcoming Open Enrollment Period or you’ve recently experienced a qualifying life event, read on for our best tips on searching, budgeting for healthcare, and enrolling in the best plan for you. (Because trust us — they’re not all the same!)
Things to consider before choosing a health insurance plan
Your health needs
Your health is everything. But there are situations (like if you’re healthy and only visit the doctor for annual preventive visits) in which you could actually be paying for healthcare you don’t need. Of course, accidents happen but think about the care you anticipate needing during the next calendar year and let that factor into your decision. If surgery or birth of a bundle of joy is on the horizon (or if you visit specialists often), it might be worth choosing a plan with a low deductible. You’ll pay a little more each month to keep your plan active, but your out-of-pocket costs (which can get pricey) will remain low.
We’ll get into specifics in a minute, but health insurance has a few different kinds of costs. To start, everyone pays a monthly premium (to keep your insurance plan active). Keep this in mind while you budget. Ask yourself — what’s the most you can comfortably pay each month to get the level of coverage you need?
Then you have your out-of-pocket costs, which you’ll have to pay when you visit certain doctors and receive services. In some cases, you don’t have to pay anything for your care! That’s because most health insurance companies offer $0 preventive checkups; but check the fine print to make sure you sign up for one that offers this benefit. If you need more specialized care, you’ll have to factor in additional, as-needed costs like co-pays and prescription drugs.
How many people you’re insuring (and their needs too)
If you’re just insuring yourself, the right health insurance plan can be a no-brainer. But if you need to factor in a spouse or dependents... things can get a little fuzzy. Think about all the same considerations — but for every individual that will be under your family plan. (Especially for any dependents.) Do you have a house full of kiddos that play team sports every night? Think about the possibility of a broken arm (or two) and how these expenses can help meet your deductible and maximum out-of-pocket (MOOP).
Your provider preference
Do you have a specialist that you’ve seen for years? Or a pediatrician that has cared for your children since day one? Health insurance companies have networks or a group of doctors and providers that have a contract to provide health services to members of their health insurance plan. Some plans (like a PPO) offer large provider networks, giving you ample flexibility. Others, like an HMO, have smaller doctor networks that require you to choose a primary care physician upon enrollment. Your primary care physician will refer you to specialists and other providers if you need to see one.
Healthcare is deeply personal — and if you’d feel more comfortable choosing a plan that has your care team in-network, make sure that is top of mind when you search. (We’d hate for you to sign up for a plan without double-checking!)
The costs of health insurance explained
One of the most confusing parts about signing up for health insurance is understanding the costs of your plan. Let’s break down each cost — and learn how you can confidently budget for it.
Premium: a set amount of money that you pay your insurance company for having an active insurance plan, usually once per month.
Budget tip: if you’re young, healthy, and typically only see your doctor for preventive services, you can save on your healthcare by choosing a plan with a lower monthly premium. Though this means your deductible will be higher, the money you save per month could help you pay for a medical emergency or specialized care, if needed.
Deductible: what you will pay annually for your healthcare needs. For example, if your plan includes a deductible of $1,000, you’ll pay the first $1,000 in covered services for the year. After that, your insurance company will cover 60-90% of the bills, depending on your plan’s coinsurance.
Budget tip: if you visit your doctor often, choosing a plan with a low deductible could help you save on your care needs. Though this might mean you have a higher monthly premium, you’ll have peace of mind knowing your insurance has you covered.
Co-pay: the amount you owe each time you receive care. This can depend on the kind of care you’re getting, though — for example, a specialist visit might cost $60, while your visit to a general practitioner might only be $30.
Budget tip: typically, co-pays cannot be used to meet your deductible, but this varies. (Be sure to read the fine print on your plan to find out.) If you’re planning on visiting a specialist, don’t forget to add this additional cost into your budget.
Coinsurance: after meeting your deductible, you still will have to pay a (smaller) portion of your medical bills, called coinsurance. For example, if you meet your $1,000 deductible in June and your coinsurance is 20%, you only have to pay 20% of each medical bill that comes your way for the remainder of the calendar year until you meet your MOOP (see below).
Budget tip: while saving on your medical bills sounds nice, if you’re someone that only visits a specialist once or twice a year, try not to get stuck on your coinsurance savings. Sticking with a high-deductible health plan can help you save more in the long run. Of course, emergencies happen — but this is where your monthly premium savings and any applicable HSA dollars can kick in.
Maximum out-of-pocket (MOOP): the most you’d have to pay each year for your healthcare needs. Once you’ve met your maximum, your insurance company will pay for any covered services for the rest of the year.
Budget tip: if you are planning on undergoing a major surgery, having a baby, or if you have a large family that needs routine medical care, pay close attention to this figure while you search for health plans. If you think you’ll meet your plan’s MOOP, make sure it’s an amount you can comfortably afford in a calendar year. If it is not, consider a plan with a higher monthly premium and a lower MOOP.
Understanding the acronyms: PPO, HMO, and HDHPs
Health insurance isn’t one-size-fits-all. As you search for health plans online, you might notice a few of these popular plans available. Understanding how each health plan works will be a big help when it comes time to create your short list.
Preferred Provider Organization (PPO): A PPO plan encourages you to use a designated network of doctors and hospitals that are contracted with the insurance plan to offer negotiated or discounted rates to insurance members. Generally, you have an annual deductible you’ll have to meet before the insurance company begins covering your bills, and you’ll usually have to pay a co-pay for your services needed. If the flexibility of a large network of doctors is important to you, consider a PPO plan.
Health Maintenance Organization (HMO): With an HMO plan, you’ll typically see lower out-of-pocket expenses (like your monthly premium) but have less flexibility in your choice of doctors or hospitals. If you want coverage with an HMO plan, you must stay in-network, meaning the doctors that accept your HMO. However, an HMO does cover preventive services and some immunizations. If you’re young, healthy, and don’t have much of a provider preference, an HMO plan might be for you.
High-deductible health plans (HDHPs) with HSA-eligibility: These plans are like a PPO plan, but with higher deductibles (meaning a lower monthly premium). Because you might have a higher deductible, those costs can be paid using a health savings account (HSA), which is a savings account that you can contribute to pre-tax and use on any qualifying medical expense — even prescription eyeglasses! Plus, your account balance rolls over each year, even if you don’t use it. If you prefer greater control over your costs and want to save money for medical expenses now and in the future, an HDHP is worth looking into.
What’s the difference between bronze, silver, gold, and platinum health plans?
In addition to the types of health plans you’ll find in your search, you’ll probably see each plan has a designated metal: either bronze, silver, gold, or platinum. This doesn’t necessarily mean you should only be looking at gold and platinum plans — it actually represents how you and your plan split the cost of your healthcare. Here’s what we mean:
Lowest monthly premium
Highest costs when you need care
Note: bronze plan deductibles can be thousands of dollars. Keep this in mind as you budget!
Moderate monthly premium
Moderate costs when you need care
Note: you’ll pay slightly less when you need care than you would with a bronze plan, but costs can still remain high (if you have a lot of health needs).
High monthly premium
Low costs when you need care
Note: if you need routine, specialized care and can afford to pay more each month, this plan could be a great value.
Highest monthly premium
Lowest costs when you need care
Note: deductibles are very low for platinum plans. But if you use a lot of care, nearly all your health costs will be covered in exchange for a high monthly premium.