Find out how to balance cost versus care when shopping for an individual health insurance plan.
Choosing the right health insurance can be a balancing act and may come down to finding a middle ground between affordable monthly premiums and adequate medical coverage for yourself or your family. Here’s how to weigh various options and find the best health insurance plan for your needs.
Assess Your Needs
One of the most important factors to consider is your personal health and the health of any dependents that may be included in your plan. If you’re young or in good health, your insurance needs may be different than that of someone who is older, has a chronic illness, or takes daily medications.
You can calculate potential medical costs for the coming year by examining your health care usage from the previous year:
- Gather the past year’s explanation of benefits
- Obtain a list of all your doctors’ visits, tests, medications, and any other health care-related expenses (you can contact your insurance plan or health care providers for help)
- Separate expenses into copayments, coinsurance costs, non-covered services, and charges applied to your deductible
These steps will allow you to see where you spent the most money — and where you may need to increase your coverage in the future.
For example, if you frequently visited the doctor in the past year, you may want a plan with lower copays. If you have a condition that requires expensive tests, surgical procedures, or hospitalizations, shop for a plan that reduces your coinsurance and deductible for those services.
If you take regular prescriptions, be sure to read the plan’s policy on prescription medications. Medication costs can add up, particularly if you can’t take a generic substitution and your plan doesn’t cover certain name-brand drugs.
Finally, be sure to figure any planned pregnancies, surgeries, or upcoming procedures into the equation.
Choose Between an HMO vs. PPO
Before deciding between an HMO and PPO, it’s important to understand the difference between these two options.
- HMOs: Health Maintenance Organization plans (HMOs) typically offer lower premiums and coinsurance costs, however, your coverage will be restricted to a specific network of physicians. In order to see a specialist (for example, a dermatologist or therapist) you will need a referral from your primary care physician.
- PPOs: Preferred Provider Organization plans (PPOs) typically cost more each month but offer greater flexibility by allowing you to see doctors outside of the plan’s network and visit specialists without needing a referral from your primary care doctor.
When choosing between a PPO and HMO, consider your needs and think about how closely you are willing to follow a plan’s restrictions. If your healthcare needs are typically limited to an annual exam and your existing primary care doctor is in your plan’s network, you may find that an HMO plan will meet your needs. However, if you’re looking for a bit more flexibility, you may find that a PPO is the better option.
Compare Your Health Care Coverage and Premium Options
If you’re buying insurance on HealthCare.gov (also known as the Marketplace), you will see plans grouped into four categories: Platinum, Gold, Silver, and Bronze. This aggregator allows you to compare plans and the various factors that control the cost and coverage levels of plans, such as premiums, copays, coinsurance, deductibles, and out-of-pocket maximums. Refer back to your healthcare expenses and determine how much you’ll be paying out-of-pocket on each plan.
Make sure to closely review the details of each health insurance plan yourself so you can match them to your specific needs.
Supplementing Your Coverage
Depending on your situation, you may want to broaden your insurance coverage. Gap insurance and hospital indemnity plans can protect you if your regular coverage falls short of a catastrophic illness or event. While they shouldn’t replace standard medical insurance, when combined with a Bronze-level plan, gap or indemnity plans could provide a layer of added protection — potentially at a lower cost than the next-highest level of coverage. However, make sure you understand what these plans do and do not cover.
Another option for paying medical expenses is a health savings account (HSA) — but it is not a health insurance plan. To qualify for an HSA, you must be enrolled in a high-deductible health plan. Although this option comes with a high deductible, the money contributed to the account is not subject to income tax when deposited.
If you’re unsure about your choices or need additional guidance, an insurance broker can help you assess your needs and compare a wide variety of health insurance plans to find the coverage you need at the cost you can afford.
