Health insurance

Start with the care you need to use

A useful health plan needs to work for your everyday care as well as unexpected illness. Before comparing prices, list your regular doctors, preferred hospitals, prescriptions and any ongoing treatment. Include the needs of everyone who will be on the plan.

Check the exact plan, not just the insurer’s name. Two plans from the same company can have different networks and drug coverage. Confirm important providers with both the plan and the doctor’s office before enrolling.

Compare the costs beyond the premium

The premium is what you pay to keep the plan. A deductible is an amount you may need to pay before the plan pays for certain services. A copayment is a set charge, while coinsurance is a share of the covered cost.

The out-of-pocket maximum limits what you pay for covered, in-network care during the plan year. Premiums, noncovered services and some other expenses do not count toward it. Check the rules for individual and family coverage.

Compare two situations: a typical year with your usual appointments and a year when someone needs substantial care. A lower monthly payment can come with more to pay when you use the plan.

Check doctors, prescriptions and referral rules

• Are your doctor, hospital and preferred specialists in the exact plan’s network?
• Do you need a referral or prior authorization for particular services?
• Are your medicines on the covered-drug list, at the dose you take?
• Which pharmacies are included, and what would each prescription cost?
• What coverage applies when you are away from home?

Keep a dated note of the answers. If you have planned treatment, ask for the coverage and authorization requirements before choosing a plan.

Understand what kind of product is being offered

Ask whether an offer is comprehensive major medical coverage, a short-term product, a fixed-benefit policy or a discount program. These are not interchangeable. A product that pays a fixed dollar amount toward a service may still leave you with a large balance.

For major medical plans, request the Summary of Benefits and Coverage. It is a useful starting point for comparing benefits, exclusions and cost sharing in a consistent format. Also check the full plan documents when a detail matters to you.

Enrollment and the date coverage begins

Do not assume you can join every type of plan at any time. Marketplace enrollment depends on the current enrollment window or eligibility for a Special Enrollment Period. Use HealthCare.gov to check Marketplace options and the route for your state.

Before ending existing coverage, confirm the new start date, any documents required and the first payment deadline. If you are moving from employer coverage or approaching Medicare eligibility, check how those dates fit together.

A practical way to compare two plans

Put the premium, deductible, out-of-pocket maximum, doctor network and prescription costs side by side. Mark any must-have treatment or provider that is missing. Ask the insurer to explain the remaining differences before you choose. If Medicare is relevant to you, our Medicare guide explains the main coverage routes.