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How to Find the Perfect Health Insurance Policy: 8 Essential Questions to Ask

Alvin Nelson
June 2, 2021
Alvin Nelson

health insurance policy

Americans who were hospitalized for Covid and don't have health insurance could face up to $75,000 in medical bills.

With rising healthcare costs in the United States, having health insurance isn't really optional. But how do you choose the right health insurance policy?

Keep reading for 8 essential questions to ask to help you find the perfect health insurance plan for your needs. 

1. How Much Does the Policy Cost?

Possibly the most important factor when choosing a health insurance policy is the cost of the plan. Finding the right healthcare plan is all about determining whether you want to pay more upfront or down the line if you should need care.

If you plan to use your insurance frequently, you can save money by paying more in premiums and less out of pocket. This is because healthcare premiums are deducted from your salary pre-tax.

If you are relatively healthy and don't expect to use your plan much, you can save money by choosing a plan with lower premiums and a higher deductible. Even if you don't expect to use your health insurance, it's important to have a plan in place in case something does happen. The cost of healthcare without insurance can be devastating.

You should also consider whether a plan includes an HSA or FSA. These options allow you to set aside money pre-tax to use on healthcare-related expenses. 

2. What Does the Policy Cover?

Next to cost, coverage is the most important consideration when finding health insurance policies. All health insurance plans sold on the marketplace must cover 10 essential health benefits. These include:

  • Outpatient care
  • Hospitalization
  • Emergency services
  • Lab tests
  • Mental health and substance abuse treatment
  • Pediatric services
  • Prescription drugs
  • Preventative services
  • Rehabilitation services
  • Pregnancy, maternity, and newborn care

Large employers with self-insured plans are not subject to this requirement, but they usually offer similar or equal coverage. 

3. What Doesn't the Policy Cover?

It's also important to know what a plan doesn't cover. While you can rest assured that your plan will cover the most essential services, you need to know that the plan you choose will cover all of your needs.

You can learn about what a plan covers in its Summary of Benefits and Coverage (SBC). If you have specific questions, you can contact an agent for more information. 

4. Are My Providers in Network?

Some people are more attached to their current providers than others. When you are shopping for a health insurance plan, you need to consider how important this factor is to you.

Are you willing to switch doctors? Or are you willing to pay more to keep seeing your current doctor?

If you want to keep seeing your current providers, you want to make sure they are in-network providers for the plan you choose. You can find out whether your preferred doctors, hospitals, labs, clinics, and even pharmacies are in-network by searching a plan's provider directory online or calling them directly.

Out of network providers will cost you more out of pocket and may not be covered at all. 

5. Do I Need a Referral to See a Specialist?

The type of health insurance plan you choose will determine how you go about seeing a specialist.

With most HMOs (health maintenance organizations), you will need to choose a PCP (primary care provider) who will refer you to an in-network specialist. With a PPO (preferred provider organization), you can usually refer yourself to a specialist.

Providers who are out-of-network will cost you more.

With a POS (point of service) plan, you will likely need a referral from your PCP to see an out-of-network specialist. If you have ongoing medical conditions that require treatment by a specialist, this could be an important factor for you. 

6. Are My Medications Covered?

Health insurance plans have what is called a formulary that determines which prescription medications are covered and what the copayment is for each drug. Copayments for drugs on this list will be lower.

If you take prescription medications, you probably want to choose a health insurance policy that covers the medications you expect to need. If a medication you take isn't covered on the plan's formulary, you may need to choose an alternative medication or plan to pay out of pocket.

You can consult the formulary list to see how much your medication refills will cost. You should also find out if there are any quantity limits, step-therapy protocols, or prior authorization requirements that could affect your ability to get your medication.

With most plans, you can save money by choosing generics over name brands. 

7. Do Prescriptions Have a Separate Deductible?

You'll want to know whether the pharmacy benefits on your plan are covered under your medical deductible or whether there is a separate pharmacy deductible.

If your plan has a separate deductible for prescriptions, it may only apply to brand-name medications. You may only owe a copay on generic versions of your medication. 

8. Are There Any Ways to Save on Prescription Costs?

Some health insurance policies offer options to save money on the costs of prescription drugs.

One of the most common options is a mail-order prescription service for maintenance medications. With this option, if you choose to have 90-day supplies of your regular medication mailed to your home, you can save money.

Finding the Perfect Health Insurance Policy

You can avoid unexpected medical bills that cost as much as a mortgage by purchasing a health insurance policy today. Be sure to ask the right questions to make sure you choose a plan that works for you.

Click here to get started and compare available plans. 

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Advertised Pricing:

There are several factors that impact your monthly premium; including your age, geographical location, annual income, dependents, and the type of plan you choose. Monthly premiums do not include out-of-pocket costs.

The advertised price may not be typical. It was generated using the Kaiser Family Foundation's subsidy calculator that was accessed on September 16, 2020. The following parameters were used: 21 year old adult, non-tobacco user, annual income of $24,700 in 2020, no children, and no available coverage through a spouse's employer. The resulting monthly premium was $30 per month (or $360 per year after $2,751 in subsidies) for a Bronze Plan. Even when using the same parameters, the resulting premium and subsidy calculations may be subject to change.