Five Questions to Ask When Picking a Health Insurance Plan

The United States has the highest healthcare costs in the world. According to the National Health Expenditure Accounts¹ (NHEA), health spending grew 7.5% in 2023, reaching $4.9 trillion, or $14,570 per person.

While the cost of care isn’t cheap, you can make it more affordable with health insurance coverage. When you work with a health insurance company, you agree to share the cost of healthcare prices with the company in exchange for a premium. Plus, depending on your health plan type, you can access in-network providers offering pricing discounts.

But, how do you know which plan is right for you? In this article, we’ll cover five of the most important questions to ask when picking a health insurance plan.

In this blog post, you’ll learn:

• How to determine the best coverage option for your needs.
• Important factors to consider when assessing the cost of a health plan.
• Why it’s important to look at each health plan’s network of doctors.

1. What type of health coverage is right for you?

This is the first question you’ll want to consider so you don’t fall short on coverage or break the bank with out-of-pocket expenses.

To find out what type of health coverage is right for you, consider the following:

• Frequency of appointments. What’s your health status? Do you rarely see your doctor? Or do you have a health condition or pre-existing condition that requires office visits regularly? If you visit a doctor or specialist often, you might need a higher level of coverage with lower deductibles.
• Family. Are you pregnant? Do you plan on having a baby? Or do you already have children who require coverage?
• Prescription drug coverage. Do you have regular prescriptions that you take daily? How much do they cost? You’ll want to ensure any plan you choose covers your prescriptions.
• Surgery. Will you require any surgeries in the near future?

Once you’ve answered these questions, you can search for health coverage options that best fit your lifestyle.

2. What does the health plan cover?

Before the Affordable Care Act (ACA), health insurance plans varied significantly in their coverage, lacking standardized requirements for included medical services. For instance, certain plans might exclude coverage for maternity care, preventive care, mental health treatments, or prescription drugs.

That changed in 2014 when the ACA mandated that all health insurance policies sold to individuals and small businesses must cover at least the essential health benefits.

The ACA considers the following ten benefits essential:

• Emergency services
• Hospitalization
• Lab services
• Maternity and newborn care
• Mental health care and substance abuse treatment
• Outpatient care (medical services you receive outside of a hospital)
• Pediatric services, including dental and vision care
• Prescription medications
• Preventive services (such as immunizations, check-ups, and screenings like mammograms) and management of chronic conditions such as diabetes
• Rehabilitation services

The rules for insurance provided by large employers (which the ACA defines as 50 or more full-time equivalent employees) are slightly different, but most will cover the same set of benefits. If you’re selecting from plans offered by a large employer and are unsure what the plans cover, ask your employer for the Summary of Benefits and Coverage² (SBC). This standard form states which products and services the coverage includes.

You can always see what individual health plans on the public and private exchanges cover by downloading or requesting the SBC.

3. How much does the health plan cost?

When looking at the cost of health insurance plans, there are several different prices to consider. Let’s look at a few different categories of costs that will help you determine how much you’ll end up paying for your plan.

Premium

Your health insurance premium is the monthly amount you’ll pay to maintain your coverage. This monthly payment won’t change during your entire plan year, so you can budget for it every month. Just like a monthly car insurance payment, you’ll pay your premium even if you don’t use your insurance to cover anything that month.

If you have a stand-alone health reimbursement arrangement (HRA) from your employer, such as an individual coverage HRA (ICHRA) or qualified small employer HRA (QSEHRA), your employer can reimburse you for your qualifying individual health insurance premiums.

Deductible

The deductible is the amount you’ll pay for covered services before your health insurance pays for anything. For example, if you have a $3,000 deductible, you’ll have to pay $3,000 on your own before your insurance starts covering your bills. Generally speaking, plans with higher deductibles have lower premiums and vice versa.

However, under the ACA, individual health plans must cover essential health benefits regardless of whether you’ve met your deductible.

Copay

A copay, or copayment, is a flat dollar amount you’ll pay your medical provider for a covered service. For example, you may have to pay a $20 copayment for each covered doctor visit to a primary care provider (PCP) or $10 for each generic prescription you get filled. Copayments vary from plan to plan but generally fall between $10 and $50.

Coinsurance

Coinsurance is the percentage of allowed charges for covered services you must pay after you’ve paid your deductible. For example, your health insurer may cover 70% of the charges for a covered hospitalization, leaving you responsible for the remaining 30%. The 30% that you pay is known as coinsurance.

Out-of-pocket maximum

An out-of-pocket maximum is the maximum amount you’ll pay for medical expenses during a benefit period (for example, over a year).

The out-of-pocket maximum never includes your premium, balance-billed charges, or services your health insurance plan doesn’t cover. The out-of-pocket maximum varies from plan to plan, but it can include copayments, deductibles, and coinsurance.

Once you have paid your out-of-pocket maximum for the year, your insurance company will pay the total amount of your covered medical expenses for the rest of the period.

Given all these different prices within one plan, comparing plans and their overall costs can be tricky. That’s why the state and federal marketplaces display individual and small group plans in standardized “metallic tiers of coverage” ranging from Bronze to Platinum, with various combinations of premiums and out-of-pocket costs.

For example, a Platinum plan generally has the highest monthly premium cost, but you’ll pay the least out-of-pocket when you receive medical care. This could be a good option if you usually require routine care, such as for chronic illnesses. With these types of plans, your insurance company agrees to pay 90% of your medical expenses, and you agree to pay the remaining 10%.

With Bronze, Silver, and Gold plans, you’ll pay lower monthly premiums but pay more when you receive medical care.

This chart covers the basic structure of those options, including the 2025 average monthly premiums from data collected by KFF ³ :

4. Can you keep your current doctor?

Every health insurance plan has a network of providers—primary care physicians, specialists, hospitals, laboratories, imaging centers, pharmacies, etc. Each health insurer has contracts with these types of medical providers that agree to provide healthcare services to plan members at a specific cost.

If your doctor isn’t in your plan’s special network, your insurance carrier may not cover the bill. In other cases, they may require you to pay a higher share of the cost. So, if you have a few favorite doctors you want to continue seeing, make sure they’re included in the plan’s provider network.

If you’re shopping for health insurance on your own, review the plan’s provider directory before you purchase the plan. If you’re looking at health insurance options through your employer, you can get provider lists from participating health insurance companies. You can also reach out to the company’s employee benefits department.

5. Where will you have coverage?

Accidents happen. One day, you may need emergency medical care while you’re away from home. Maybe you catch a cold while you’re away on vacation. Either way, what happens when you’re far from your in-network doctors?

To ensure you’re fully covered, check how the plans work when you’re out of state or traveling abroad. Most plans cover visits to emergency rooms and urgent care centers anywhere in the world, but it’s always good to double-check the details.

It’s also helpful to know if a plan offers telemedicine services or virtual visits where you can use your mobile device to easily connect with a doctor.

Conclusion

Choosing a health insurance plan can seem daunting at first, but by asking yourself these five simple questions, you’ll be well on your way to finding a health insurance policy that meets the needs of you and your family. Whether you frequently require medical care or just see a doctor annually, there’s a plan tailored to your specific cost and coverage preferences.

This article was originally published on October 31, 2013. It was last updated on May 6, 2025.

1. Centers for Medicare & Medicaid Services
2. Health insurance rights & protections
3. KFF Average Marketplace Premiums by Metal Tier, 2018-2025