How do you pick a health insurance plan?

Answer 1

Health care can be very expensive. Having a baby costs about $30,000, and so does the average three-day hospital stay. Health insurance is a way to reduce those costs to an amount that you can manage by sharing the risk with others. That works because most people are mostly healthy most of the time, so their premiums help pay for the expenses of the small number who are sick or injured.

Here are the three major questions you need to ask when picking a plan.

1. What does the plan cover?

Insurance sold to people and small businesseses must cover 10 "essential health benefits." Any plan you buy, whether through your state's Health Insurance Marketplace or not, will pay for these services.

a. Emergency services

b. Hospitalization

c. Laboratory tests

d. Maternity and newborn care

e. Mental health and substance-abuse treatment

f. Outpatient care (doctors and other services you receive outside of a hospital)

g. Pediatric services, including dental and vision care.

h. Prescription drugs

i. Preventive services (such as immunizations and mammograms) and management of chronic diseases such as Diabetes

j. Rehabilitation services

2. How much does the plan cost?

You pay for health insurance in two ways:

The monthly premium that you pay to purchase your plan.

The out-of-pocket expenses you pay when you receive medical care. Those are some combination of deductibles, coinsurance, and copays.

In general, if you pay a higher premium upfront, you will pay less when you receive medical care, and vice versa.

If you purchase coverage through your state's Health Insurance Marketplace, you may be eligible for income-based subsidies that lower the cost of your premium and in some cases your out-of-pocket expenses.

3. Which doctors and hospitals are in it?

Every health insurance plan has a network of providers-doctors, hospitals, laboratories, imaging centers, and pharmacies that have signed contracts with the insurance company agreeing to provide their services to plan members at a specific price.

If a doctor is not in your plan's network, the insurance company may not cover the bill, or may require you to pay a much higher share of the cost. So if you have doctors you want to continue to see, you will want them to be in the plan's network.

Some state Health Insurance Marketplaces, including those operated through the federal HealthCare.gov site, have links to provider directories that you can see before you buy. But the directories are not standardized and may be hard to use or out of date. Moreover, to keep costs down, many of the plans sold through the state Health Insurance Marketplaces have smaller networks than you may be used to. That is why you should check and double-check with the health plan and your doctor's billing office to make sure your desired providers are in the network of the plan you are considering.

If you are given a choice of insurance through a job, you can obtain provider lists from participating insurance companies, or from the company's employee benefits department.