Finding affordable health care can be tricky. Determining which plan gives you more of what you need for a better price among available options can feel like comparing apples to oranges. If you need to choose between different health insurance plan options, the following are some key factors to keep in mind.
The Health Care Network
Most health insurance programs coordinate care with a network of providers, which includes individual doctors, hospitals, and other medical facilities. The insurer has negotiated a lower price for care from in-network providers, so insured individuals can expect to pay less for medical care from in-network providers.
The health care network available to you through your insurance may be one of the most important considerations for both expected cost and level of care. If you have an established relationship with a doctor, you likely will want to find a health insurance plan that includes that doctor in its network so you do not have to pay a premium to continue seeing the physician.
Even if you do not already have a doctor, keep in mind that your health care plan can limit options for which doctors you can see in-network.
You can compare available doctors in various networks by researching potential doctors’ credentials, by reading online reviews on reputable sites, and checking with the American Medical Association (AMA).
Your insurance plan also will include hospitals and emergency medical centers in the network. Comparing which hospitals are part of each plan’s network can help you determine which insurance will best serve you in case of an emergency. Which plan offers multiple options for local hospitals?
Don’t forget to check how each plan defines “emergency care.” If there is a threshold in terms of patient condition, deductible, or procedure coverage you need to meet for emergency care for your insurance coverage to kick in, you will want to know this before dealing with a serious injury or illness.
That said, according to Healthcare.gov, the health insurance exchange website operated by the federal government to provide information about provisions of the Patient Protection and Affordable Care Act (ACA), your insurance company can't charge you more for getting emergency room services at an out-of-network hospital.
So, while it is helpful to have a health care plan that includes several local hospitals in its network, know that you can go to whichever hospital is closest in an emergency.
If you have specific medical conditions or believe you may need to see specialists in the future, find out if you will be able to see a specific specialist, and what the procedure is. Some health care plans require a referral before you may see a specialist, and other types of health insurance do not. If you already have a specialist, see if they will be accepted by the insurance company you’re considering.
Unfortunately, the cost of health insurance is not a simple calculation. Not only do you have to compare premium prices, you also have to understand the out-of-pocket costs, including deductibles, copays, and coinsurance.
Understanding how all costs inherent in a particular plan work and how much you can expect to pay for each may help you compare health plans to find the right one for your needs.
This is the monthly payment you make to your insurer for your health care plan. In general, lower premiums are associated with higher deductibles, copays, coinsurance, and prescription drug costs. That means a lower-premium health care plan may be a good choice for someone with few existing health care needs, as they are less likely to require the care that will result in out-of-pocket costs.
The premium often is the easiest cost to compare with other health care plans, as each plan clearly states the premium. But it’s important to include out-of-pocket costs in your calculations to ensure you have a true understanding of how much a plan will cost.
Most insurance plans require the insured individual to pay a certain amount before coverage kicks in. For instance, let’s say your health insurance plan has a $1,000 deductible, and you need to have a covered procedure that costs $2,500. If you have not paid for any medical services yet this year, you will have to pay $1,000 toward your covered procedure; your insurance will cover the rest—at the level laid out by your plan.
Your plan may cover certain preventive services, such as checkups or disease management, before you meet your deductible. Additionally, some plans have separate deductibles for medical services and prescription drugs—meaning you will have to meet these separately before coverage kicks in for each. Generally, family health care plans also have individual deductibles for each person plus a family deductible for the entire family.
When you compare the deductibles of various plans, take into account the premium savings a higher deductible provides you, as well as your ability to pay the deductible before coverage begins.
Copay and Coinsurance
There are two ways an insured individual is responsible for a portion of the cost of their care. The first is through a copayment. This is a fixed amount of money you pay toward your care after you meet your deductible.
For instance, let’s say you have a $30 copay and your doctor’s office visit costs $150. If you have met your deductible for the year, you will pay $30 for the visit. If you haven’t yet met your deductible, you may have to pay up to the entire cost of the visit, depending on the plan’s copay amount provision. Copays often vary within the same plan for various services, such as prescription drugs, lab tests, doctor visits, etc.
Coinsurance refers to the percentage you have to pay for covered services after you reach your deductible. Let’s say your plan pays for 80% of covered procedures. If you have not met your $1,000 deductible and need a $2,500 covered procedure, you will end up paying $1,000 toward it to cover your deductible, plus 20% of what remains, or $300. (20% of $1,500 is $300.) Insurance will cover the remaining $1,200.
Deductibles, copays, and coinsurance amounts often are subject to an out-of-pocket maximum. If you reach this spending limit on covered services by in-network providers, your health plan will pay 100% of covered services for the remainder of the plan year.
In addition to the out-of-pocket costs that you need to consider as you compare insurance plans, you will also need to check on the lifetime limits for each plan. This limit is the cap on benefits you can receive from the health care plan for any covered services.
In some cases, the lifetime limit will be listed as a single dollar amount (such as $1 million) for all services. Other plans may have individual lifetime limits for certain services, such as a $200,000 limit on organ transplants. Reaching a lifetime limit means your insurance plan no longer will pay for any covered services.
Choosing a plan with a low lifetime limit could place you in serious financial hardship, should you face a major medical issue.
A waiting period is the amount of time that must pass after joining a health care plan before the plan will pay for covered care.
If you have a pre-existing condition, make sure you confirm how the plan covers such conditions, and whether there are waiting periods that will affect your current care.
Regular Physicals and Health Screenings
Many health care plans cover preventive care such as regular physicals and health screenings, even before you meet your deductible. When you compare potential health care plans, find out what is covered by each as part of a wellness plan, or is included as preventive care—and if there are any limitations. If you have young children, find out if baby or child checkups and immunizations are covered.
Prescription Drug Coverage
The out-of-pocket costs for prescription drugs can vary a great deal from plan to plan. Checking the level of coverage for prescriptions may include asking the following questions:
- Are you required to get a generic version of any drug you are prescribed?
- Is there a specific prescription drug copay?
- Are all the prescriptions you currently take covered by the plan?
Patients who visit an obstetrician or gynecologist need to make sure their reproductive-health needs are covered by any health care plans under consideration. In addition to checking if your current OB-GYN is in-network, it’s a good idea to look over the coverage provided for pregnancy, birth, and postnatal care. While all qualified health plans are required to cover pregnancy and childbirth, the levels of coverage may vary from plan to plan. Determining how much you can expect to pay out-of-pocket for pregnancy and birth care can help you determine which plan is right for you.
It’s also important to note that all health plans purchased through the federal insurance marketplace cover pregnancy and childbirth, even if your pregnancy began before your coverage did.
Consider what additional services are covered when comparing health plans. Some examples of these services include: drug and alcohol rehabilitation, mental health care, counseling, home health care, nursing home care, hospice, experimental treatments, alternative treatments, and chiropractic care.
Pay careful attention to the exclusions and limitations of each prospective policy. Exclusions are provisions written into insurance policies that eliminate coverage for certain services. The insurance policy does not pay for excluded services, and your out-of-pocket payment for those services does not count toward your deductible, your annual out-of-pocket maximum, or your lifetime limit.
Knowing which exclusions are part of a health care plan can help you avoid any plans that might leave you on the hook for needed health care services.