10 Essential Questions to Ask Before Choosing a Health Insurance Plan
Choosing the right health insurance plan can feel overwhelming, but by asking the right questions, you can find a plan that meets your health needs and fits your budget. To help you make an informed decision, we’ve compiled a list of the most important questions to ask before selecting a health plan.
1. What Does the Plan Cover?
Health insurance plans are required to cover certain essential health benefits, but the details of what’s included can vary significantly. You’ll want to check that the plan covers:
Doctor and specialist visits
Hospital care, including surgeries and emergency services
Preventive care, like vaccines, annual physicals, and cancer screenings
Prescription medications
Maternity and newborn care
Mental health services and substance use treatment
If you have specific medical needs, such as regular therapy sessions, long-term prescriptions, or planned surgeries, make sure the plan covers these services without excessive restrictions. Understanding exactly what the plan covers will prevent surprises later when you need care.
2. What Are the Total Costs?
When comparing plans, it’s easy to focus on the monthly premium. However, that’s only part of the cost. Be sure to evaluate the following:
Premium: This is the amount you’ll pay each month to keep your coverage active.
Deductible: The amount you need to pay out-of-pocket each year before the insurance company starts covering your medical expenses.
Copays and Coinsurance: Even after your deductible is met, you’ll likely pay a portion of the costs for doctor visits, prescriptions, and other services.
Out-of-Pocket Maximum: This is the most you’ll have to pay in a year for covered services. Once you reach this limit, the insurance company will cover 100% of your medical costs for the remainder of the year.
It's essential to find a balance between the premium and the out-of-pocket costs. For example, a lower premium might seem attractive, but if the deductible is too high, it may not be affordable when you actually need care. Make sure to calculate what you’ll likely spend annually on healthcare to choose the best plan for your budget.
3. Are My Preferred Doctors in the Plan’s Network?
Health plans usually work with a network of doctors, hospitals, and healthcare providers. If you have doctors you trust or want to continue seeing, confirm they’re part of the plan’s network.
Going outside the network may result in higher out-of-pocket costs or no coverage at all, depending on the plan. For instance, some plans like HMOs (Health Maintenance Organizations) may not cover out-of-network providers at all, while PPOs (Preferred Provider Organizations) typically cover a portion of the costs.
It’s worth checking the network size and the reputation of healthcare providers in the network, especially if you’re considering switching doctors.
4. Are My Prescription Medications Covered?
Prescription drug coverage can vary widely between health insurance plans. Some plans have a formulary, or list of covered drugs, that may include your medications but at different tiers. Medications in higher tiers usually come with higher copays or coinsurance.
Be sure to check:
If your specific medications are covered.
What copays or coinsurance you’ll be responsible for.
Whether the plan requires you to try cheaper medications (step therapy) before covering your prescription.
If you rely on regular medications, understanding the prescription drug coverage is crucial to avoid unexpected costs.
5. Can I See a Specialist or Out-of-Network Provider?
If you need specialized care, you should confirm whether the plan requires a referral from your primary care physician before you can see a specialist. Some plans, like HMOs, require referrals, while others, such as PPOs, allow you to see specialists without one.
Additionally, it’s important to know how the plan handles out-of-network care. While most plans cover emergency care regardless of the provider, non-emergency out-of-network visits could come with much higher costs—or may not be covered at all. If you prefer flexibility in choosing doctors, a PPO or POS (Point of Service) plan might be a better fit, as these plans tend to offer more freedom to see out-of-network providers.
6. What Is the Process for Referrals and Prior Authorizations?
Some health insurance plans require referrals or prior authorizations for certain treatments or specialists. This means your primary care physician must approve your visit to a specialist, or the insurance company must authorize a procedure before it’s covered.
Understanding the rules for referrals and prior authorizations can help prevent delays in your care. Be sure to ask how easy it is to get these approvals and whether they typically lead to any delays in treatment.
7. Are There Wellness Programs or Additional Benefits?
Many health insurance plans offer additional benefits to support your overall well-being. These might include:
Gym membership discounts
Wellness programs, like smoking cessation or weight-loss counseling
Access to telehealth services
Discounts on dental or vision care
These extras can add real value to your insurance, especially if you’re looking to maintain or improve your health. Be sure to explore whether the plans you’re considering offer any of these added benefits.
8. How Is the Plan Rated for Customer Satisfaction?
It’s important to check how other customers have rated the health insurance plan in terms of satisfaction. Factors to look for include:
How quickly and easily claims are processed
The quality of customer service and support
How well the plan handles disputes or issues
Overall satisfaction with the coverage provided
A plan may look great on paper, but if it’s known for poor customer service or slow claims processing, it could lead to frustration when you need help the most. Many insurance review websites and resources can give you insight into a plan’s performance.
9. What Happens If I Need Care While Traveling?
If you travel frequently, either domestically or internationally, you’ll want to know how the plan handles care outside your local area. Most plans cover emergency services anywhere, but non-emergency care might not be covered outside of your network.
Ask if the plan offers nationwide or international coverage, especially if you travel for work or pleasure. This can help ensure you’re protected no matter where you are.
10. Are There Penalties or Fees for Canceling the Plan?
Before committing to a health insurance plan, ask about the terms and conditions if you need to cancel or switch plans. While there may be no penalties for canceling during the open enrollment period, leaving a plan outside of that window could come with fees or restrictions.
It’s important to fully understand the cancellation policies, especially if you anticipate any changes in your health or employment situation that could require you to switch coverage mid-year.
Choosing the right health insurance plan doesn’t have to be complicated when you know what questions to ask. By understanding the coverage, costs, and flexibility of each plan, you can confidently make a decision that suits your needs.
Need help reviewing your current policy or comparing new options? We offer a free policy review to help you find the best coverage for your situation. Contact us today to schedule your review!
