1. How often do I need care?
Consider your past and future medical bills. If you are healthy and don’t expect to need many costly medical services throughout the year, then a Bronze plan – typically with the lowest premiums and highest costs for care – might be a good fit for you. If you or your family have a medical condition or are planning to have any surgeries, then a Silver or Gold plan that pays more of your medical costs (but has a higher monthly premium) might cost you less overall. Learn more about plans on our Types of Plans page.
2. What services do I need?
Write down what medical services you and your family routinely use. For each plan you are considering, read the Summary of Benefits and Coverage (SBC) to make sure they are covered. Reminder: Preventive services – such as an annual check-up or a flu shot – are usually free, when delivered by an in-network provider.
3. How much can I afford?
Think beyond the monthly premium amount and imagine what your costs might look like throughout the year. Consider the deductible – how much could you afford to pay upfront, in the case of a bad accident or serious illness, before your insurance starts to help you pay? Then, once the insurance kicks in, what is the coinsurance – the percentage of the bill you will have to pay? What about prescriptions and doctor visits – do you have a copay (fixed amount) or will you pay the full cost until the deductible is met? What is the out-of-pocket maximum? The most you’d ever have to pay for covered services and prescriptions in a plan year, not including your monthly premium.
4. Is your preferred provider covered under your plan?
If you have specific doctors, hospitals and pharmacies that you prefer to use, make sure they are in-network (part of the provider network) for the plan you are considering. Most plans won’t pay much, or anything if you go out-of-network (and those costs won’t count towards your deductible or out-of-pocket maximum). Because doctors can change insurance networks frequently, we recommend contacting the health insurance company to confirm that your doctor is covered by a plan before you buy.
Did You Know? Networks change from plan to plan. If your doctor is in-network (covered) by one health insurance company’s plan, do NOT assume that he/she is covered by ALL plans offered by that insurance company.
5. Are my medications covered?
Not all health plans cover all prescriptions. Each insurance company has a list of prescriptions they cover, called a formulary or drug list, on their website. These lists often split drugs into ‘tiers’ or categories, which determine your share of the costs. While some plans have a copay for prescriptions, a fixed amount that starts right away, other plans require you to pay the full cost until you hit a prescription deductible (if there is one) or your overall plan deductible (which is more common).
Generics can save you money: There may be multiple brand and generic medications that address the same health issue. Generic options cost less than the brand name drugs and are typically covered by a larger number of health plans. Ask your doctor if a generic is right for you. Because a plan can change its covered medications at any time, we recommend checking with the health insurance company to confirm that a particular medication is covered by a plan before you buy.
6. What services are covered?
All health insurance plans must cover a specific list of Essential Health Benefits including hospital stays, ER care, outpatient care, maternity and newborn care, prescription drugs, free preventive tests and services, mental health and substance use disorder services, rehabilitative services and devices, lab tests, chronic disease management, and pediatric services including care for children. Beyond that, plans can vary greatly.