Choosing a Plan That’s Right For You

Insurance plans require you to pay a monthly fee, much like you pay for a cell phone or for electricity.  Many families choose a health plan with a low monthly fee (premium) to fit their budget.  However, the health insurance premium is not the only thing that you should think about when choosing a plan that you can afford.

For many plans, you have to pay a certain amount for health care out of your own pocket (a deductible) before the health insurance plan begins sharing  your health care costs. For some people, a large deductible is a good choice since it will help you limit the monthly fee you pay for insurance (premium).  For others (especially those who plan on needing a lot of health care services), a high deductible may end up costing you more for their health care in the long run.

You may also want to look at the co-payments, co-insurance, or maximum out-of-pocket costs.  All of these terms describe how much you will have to pay for health care when you receive it.

All health care plans on the Health Insurance Marketplace at healthcare.gov include at least the same basic types of services.  These include:

• Visits to your doctor
• Hospital bills, including visits to the emergency room
• Medical tests like x-rays
• Care before and after your baby is born
• Medicine
• Behavioral health and substance abuse treatment
• Services and devices that help you recover if you are injured, have a disability, or serious, ongoing health problem, like physical or speech therapy
• Dental and vision care for kids
• Preventive services, like vaccinations and cancer screenings

However, there may still be differences among plans. For example, one plan may cover infertility treatment and another may not.  Or one type of plan may pay for a specific type of medicine, and another plan may not.  Plans may also charge you different amounts for services and medicines.

Here are some questions that may help you think about your specific health care needs:

• Does the plan cover the specific services and medicines that you need? For example, if you have a disease such as hemophilia, does the plan include the specific type of medicine that you need?
• How many times each year will the plan pay for the specific services that you need? For example, one plan may pay for 20 physical therapy visits, while another may pay for 40.
• How much will you have to pay for a specific service or medicine? For example, one plan may charge $20 for each doctor visit while another may charge $10. If you expect to visit the doctor a lot, this difference may make a big difference to how much it will cost you to get the health care you need.

There are several ways you can find information about the services and medicines a plan covers:

• Visit https://www.healthcare.gov/see-plans/ to see plans offered in your area.
• Click on the Summary of Benefits under each health plan you are considering. Here you will find the types of services that insurance will pay for and their cost to you.
• If you still need more information about the services the health insurance plan will pay for, contact the health plan. Ask for the plan’s “Evidence of Coverage” document or talk to a plan representative. (Whenever possible, get the information you need in writing.)
• Check the plan’s drug formulary for a list of which medicines the plan will pay for and how much you will pay (co-payments or co-pays) for the medicine.  Visit https://www.healthcare.gov/see-plans/  and click on Summary of Benefits to find out how to get a copy of the plan’s drug formulary.
• If you can’t find a health plan that covers a medicine that you need, talk to your doctor. Your doctor may be able to identify another medicine that is covered by an available health plan.  If not, you and your doctor should talk to the plan about how you can get that medicine. All plans must allow you to get the medicine you need, even if a plan does not normally pay for it.

For some people, it is important to see a particular doctor or health care provider (like a hospital).  If that is important to you, you should:

• Click on the Provider Director on https://www.healthcare.gov/see-plans/ to make sure the doctor or hospital that you want is included in the health plan’s list.
• Make sure that the doctors or hospitals that you are considering are “in-network.” Care delivered by out-of-network providers may cost you a LOT more.
• Call both the health care provider and the insurance company to double check that the health care provider is “in-network.” Provider directories listed online are not always up-to-date.

For other people, it is not that important to see a particular health care provider. Still, you may want to consider:

• Does the health insurance plan include providers that are close to me? In some instances, a plan may not offer health care providers in your area, making it inconvenient to get the care that you need. This problem has been more likely to occur for some PPO health insurance plans.
• Does the health insurance plan include a limited number of providers? Some types of health insurance plans include “narrow networks,” which means that the health insurance plan will contract with relatively few health care providers.  In some instances, these types of plans offer you a better monthly price (premium) for your health care, but you should be aware that you may have fewer options when choosing a health care provider before selecting this type of health insurance plan.