How to Compare Health Insurance Plans Beyond the Monthly Premium
Health insurance can feel like a page full of numbers. The easiest way to compare plans is to connect those numbers to the care you realistically expect to use. Start with your doctors, prescriptions and household needs, then review both routine and worst-case costs.
What you pay to keep the plan.
Deductible, copays and coinsurance.
Out-of-pocket limit plus premiums.
1. Begin with the monthly premium
The premium is the amount paid to maintain coverage, whether or not you use medical services that month. If you are shopping through the federal Marketplace, any premium tax credit for which you qualify can change your net monthly cost. Marketplace savings are determined through the Marketplace based on the information in your application.
Do not stop at the premium. A plan with a higher premium may have a lower deductible, lower copays or a network that better fits your needs.
2. Understand the deductible
The deductible is the amount you generally pay for covered services before the plan begins paying for many benefits. Some plans cover certain services before the deductible, such as specified preventive care or office visits with a copay. Family plans may have both individual and family deductibles.
Ask which services apply to the deductible and whether medical and prescription deductibles are combined or separate.
3. Compare copays and coinsurance
A copay is usually a fixed amount for a covered service, such as an office visit. Coinsurance is generally a percentage of the plan's allowed amount that you pay after applicable requirements are met. A plan may use one, both or different cost-sharing rules for different services.
A stated dollar amount, subject to the plan's rules.
A stated percentage of an allowed amount, subject to the plan.
4. Find the out-of-pocket limit
The in-network out-of-pocket maximum is a key number for a high-use year. After your spending on covered in-network essential health benefits reaches the plan's limit, the plan generally pays 100% of covered in-network benefits for the remainder of the plan year. Premiums, noncovered services and many out-of-network charges generally do not count toward that limit.
Compare both the individual and family limits, and read the plan documents for the exact rules.
5. Verify the provider network yourself
Check whether your primary doctor, specialists, preferred hospital, laboratories and other important facilities participate in the exact plan—not just with the insurance company generally. Provider directories can change, so confirm with both the plan and the provider before enrolling or scheduling nonemergency care.
Also review referral rules and out-of-network benefits. Some plans offer little or no out-of-network coverage except as required for emergencies or other protected services.
6. Check every prescription
Look up each medication in the plan's formulary. Note its tier, copay or coinsurance, deductible, quantity limit, prior authorization and step-therapy requirements. Confirm that a convenient in-network pharmacy participates and whether mail order changes the cost.
Formularies can change, so review current plan documents and contact the plan for medication-specific questions.
7. Compare plans using realistic scenarios
Estimate costs under several possibilities rather than trying to predict one perfect year.
Preventive care, a few visits and routine prescriptions.
Known specialists, therapies, tests and medications.
Hospital care or ongoing treatment approaching the limit.
8. Read the Summary of Benefits and Coverage
The Summary of Benefits and Coverage, plan brochure, provider directory and drug formulary work together. Review exclusions, prior-authorization rules, referral requirements and coverage for services important to your household, including mental health, maternity, therapy, durable medical equipment, pediatric care, dental or vision benefits.
Put these eight numbers and answers side by side.
- Net monthly premium
- Individual and family deductibles
- Primary, specialist and urgent-care cost sharing
- Emergency and hospital cost sharing
- Individual and family out-of-pocket limits
- Doctors and hospitals in network
- Medication tiers and requirements
- Referral, authorization and out-of-network rules
Frequently asked questions
Is a lower deductible always better?
Not automatically. Lower-deductible plans may have higher premiums. Compare likely annual cost, network, prescriptions and financial risk together.
Does the out-of-pocket maximum include premiums?
Generally no. Premiums are typically separate, and noncovered or certain out-of-network charges may not count. Review the plan's specific documents.
Can I change health plans at any time?
Enrollment is generally limited to an annual enrollment period unless you qualify for a special enrollment opportunity or another applicable exception.
Talk with our team about available health plan options.
We can help explain plan features and guide you through the available application process.
Disclaimer: This article is general educational information and is not medical, legal, tax or coverage advice. Benefits, networks, formularies, eligibility, enrollment opportunities, pricing and financial assistance vary by plan and applicant. Review official plan documents for complete terms.