A Beginner’s Guide To Picking The Health Insurance That’s Right For You
How To Find The Right Coverage
Back in 2017, I lost my job during a company-wide layoff. I still remember making my way through heaps of paperwork about my health insurance, now untethered to my workplace. I’d always been on my parents’ plan up until that point—an un-ironic thanks, Obama—but since I’d turned 26 that year, I was on my own and my naivety showed.
HMO? PPO? HDHP with an HSA? The sheer number of acronyms alone made my head spin, and the details for each plan were equally confusing. I pay a deductible and then insurance kicks in—but then not always? Because of co-insurance?
Since that time, I’ve navigated the health insurance game again (because that’s what it is in the US, right? A game?). I’ve figured out what it all means, what my needs are, and how to find the best care for my situation.
Now I’m here to demystify the process for you too, because we all deserve to understand and have access to quality medical care.
Health Insurance Terms To Know
We can’t get into US health coverage if we don’t know what we’re covering! Let’s review the most important health insurance terms first. For less common terms, visit Healthcare.Gov’s glossary; independent insurance companies usually have their own glossaries as well.
And a reminder: The costs outlined below are examples and will range based on your specific plan.
Deductible: The amount you pay before your insurance pays. For example, if your deductible is $1,000 annually, you pay those fees out-of-pocket first before insurance contributes. These deductibles can range from $0 to $5,000+ depending on your plan. Copays (defined below) do not go towards your deductible.
Coinsurance: Coinsurance is what you owe after you’ve paid your deductible. Say you’ve already met your $1,000 deductible for the year, then have a $500 treatment. If your coinsurance is 20%, you would owe $100. Once you’ve hit your out-of-pocket maximum for the year (defined below), your coinsurance phases out.
Copay: Copays are fixed amounts for services within your health insurance plan. This is what you normally pay right when you arrive at a medical provider. For example, a lab test or specialist visit may cost $50, whereas a visit to an urgent care provider may cost $75.
Flexible Spending Account (FSA): As a supplement to insurance, Flexible Spending Accounts are employer-based plans which cover out-of-pocket medical expenses tax-free. (This is not an alternative to insurance but rather a way to help offset extra medical costs.)
Each paycheck, an untaxed amount will go into your FSA until you hit your predetermined limit. You can then use the money throughout the year towards copayments, deductibles, prescriptions, medical devices, and even over-the-counter needs like Tylenol or tampons. This fund is typically “use it or lose it,” as you’ll need to use it by the end of the year. Some employers allow $500 to roll over to the next year or grant additional time to use the leftover money.
Health Savings Account (HSA): Similar to FSAs, Health Savings Accounts use pre-tax funds to pay for medical expenses—but they are only available through High Deductible Health Plans (HDHP). Check with your employer or within the Marketplace to see if your plan is HSA-eligible. Because HDHPs offer lower monthly premiums but higher deductibles, a Health Savings Account can help cover those higher costs. Funds in an HSA do roll over year to year, and again, this is supplemental to your insurance.
Network Provider (in/out): There are two types of providers you’ll have in an insurance plan, in-network and out-of-network. In-network providers work with your insurance company to offer competitive, discounted rates for their services, whereas out-of-network providers are typically not covered. One example: An in-network provider may offer X-rays with a $20 copay. An out-of-network provider may charge you a $30 copay and the full cost of the X-ray, which you’ll need to pay out-of-pocket.
Out-of-pocket Maximum (OOPM): Out-of-pocket Maximum is the most you’ll ever have to pay for covered services within the calendar year, though this doesn’t include monthly premiums or out-of-network care. If your OOPM is $5,000 and you’ve spent this across deductibles, copayments, and coinsurance, the health insurance plan will then cover 100% of costs. This number, like your deductible, will be proportionally adjusted based on individual or family plans; for example, your individual OOPM may be $5,000, whereas your family’s total OOPM may be $10,000.
Premium: Premiums are monthly payments to your health insurance plan, not unlike a recurring subscription to Netflix or a phone payment. If your employer offers health insurance, this premium is taken out of your paycheck directly. If you purchase your health insurance through the marketplace, you pay the premium manually or set up auto-pay. Keep in mind that sometimes higher premiums are a better fit for your needs (we’ll get to that in a second!).
Common Health Insurance Plans
There are four main types of health insurance plans: HMO, PPO, EPO, and POS. Technically, any of the plans can qualify as a High Deductible Health Plan which we covered above, so keep that in mind.
HMO: A Health Maintenance Organization (HMO) plan typically offers lower premiums, deductibles, and copays for your medical needs. However, you can only see doctors within the network, and you’ll need a referral from your primary care physician if you need a specialist (like a therapist, gynecologist, or podiatrist). This plan is a good fit if you don’t have any ongoing medical issues and you want a lower monthly premium.
POS: Point of Service (POS) plans are similar to HMOs—you’ll pay less for in-network coverage and you still need a referral to see a specialist. However, POS plans cover out-of-network doctors as well. While the premiums may be slightly higher, this is the best fit for managing ongoing issues if you know your preferred doctors aren’t in-network.
PPO: A Preferred Provider Organization (PPO) has higher premiums than an HMO, but you can see specialists and out-of-network doctors without a referral—skipping the step of seeing your primary physician—and copays and coinsurance for in-network doctors are low. This plan allows for the most freedom and coverage (like finding, say, a new therapist) but also comes with a higher monthly payment.
EPO: Exclusive Provider Organization (EPO) is less common for employers to offer, but it is most similar to an HMO. With an EPO, you’ll only be covered for in-network care, but that network is typically larger than an HMO. You’ll pay a bit more in premiums for that convenience.
Each of these plans also has four “metal” categories to structure your monthly premium options: Bronze, Silver, Gold, and Platinum. These don’t affect your quality of care but how much you’ll pay towards your plan. Bronze plans have the lowest monthly premiums but the highest costs of care, whereas Platinum plans have the highest monthly premiums but the lowest costs and deductibles.
Healthcare.gov shares that Bronze plans are a good choice “if you want a low-cost way to protect yourself from worst-case medical scenarios,” and Platinum plans are for you if you (or your family) “usually use a lot of care and are willing to pay a high monthly premium, knowing nearly all other costs will be covered.”
Determining The Best Plan For You
Now that we’ve reviewed the most common terms and plans, hopefully you feel a bit more empowered to find your preferred coverage! Here’s a step-by-step on picking, finalizing, and using your health insurance plan. (Remember, some states mandate enrolling in health insurance, or you’ll be penalized on your taxes.)
1) Figure out where your coverage is coming from and your timeline.
There are two primary ways to sign up for health insurance, either through an employer or directly via the Marketplace.
Both options go through the Open Enrollment Period, the same time every fall where you can enroll in a new health insurance plan for the next calendar year. For 2022 coverage, for example, Open Enrollment runs from November 1, 2021 through January 15, 2022.
But, because life happens, the government also offers a Special Enrollment Period. Special Enrollment allows you to enroll at any time of year if you’ve gone through a major life change, like getting married, moving, having a baby, or in my case, losing a job (which also came with COBRA support so I could continue my same level of coverage until finding a new employer-based plan). You’ll have to apply to qualify for Special Enrollment.
And if you’ve started a new job (congrats!), a company-based plan will give you a deadline to enroll in health insurance, and they’ll usually pay for part of your premium each month. For example, if you start a new job on July 6, you may have until August 1 to finalize your insurance coverage for the rest of the year, and your employer may cover a set percentage of costs—or if you’re lucky, 100%! Then, if you continue working at the same employer the following year, you’ll go through the regular Open Enrollment timeline.
2) Understand your needs.
Our bodies are wondrous things, and of course, no two are alike—so it’s most important to understand your own needs (and your family’s) first before looking at plans.
Consider if you or a family member have a pre-existing condition or ongoing disability and what that medical care looks like. Thanks to the Affordable Care Act, health insurance plans can no longer deny coverage to anyone with a pre-existing condition, though you will want to check your new insurance provider’s coverage before switching plans.
Personally, I have manageable conditions like PMDD and anxiety, but I don’t need ongoing appointments. On the other hand, I loved my former therapist, who was originally in-network and then moved out-of-network. If I wanted to keep seeing her, I would have needed a plan that included her coverage or risk paying for every session entirely out-of-pocket.
Here are some questions to ask yourself or anyone else who may need coverage:
How many family members do you need coverage for?
Do you have a preferred doctor you’d like to continue seeing and have in-network?
Do you have ongoing medications or prescriptions you’ll need covered? Or would generic brands work just fine?
Do you foresee any large life changes (e.g., pregnancy) this year?
Do you have specific coverage needs outside of doctor’s visits or lab work, like physical or mental health therapy, fertility treatments, or infusions?
Do you require vision and dental care? (This is usually separate from your medical insurance, but dental and vision insurance can be included in a package.)
Do you need an FSA or HSA-eligible plan for ongoing medical expenses?
What are your ideal monthly premium, copays, and deductibles?
These responses will look different for everyone, and not every plan available to you will check all the boxes. It’s better to know though, so you can thoughtfully explore your options without getting too bogged down by charts or names like “Personal Plan EPO Bronze Basic 500” (but now you mostly know what that plan name means!).
3. Parse through your available plan options.
By this point, you may know that your family needs a plan with a higher premium, a lower deductible, freedom to see specialists, and specific doctors in-network. Now’s the time to see if you can find this within your options!
There are a few ways to see your plans:
Your employer may send you a sheet like this comparing different options or premiums
If you’re purchasing directly, log on to Marketplace to compare plans and preview prices
Connect with a Marketplace-registered agent to walk through your options
Carefully go through each plan line-by-line to see which coverage most aligns with your health audit above. As you narrow down, use the “deductible”, “co-pay”, “out-of-pocket maximum”, and “premium” lines to get a sense of which “metal” category will be the right fit.
You can even build a spreadsheet to project the cumulative costs of each plan, taking into account the average number of visits or services you need over a year (e.g., two preventative visits, three specialist visits, one ongoing prescription).
4. Finalize enrollment.
You’ve hopefully found a plan that ticks all the boxes—hooray!
Double- and triple-check that your preferred plan has the coverage you’ll need for everyday providers and necessary care, and that the costs fit within your budget.
If your employer covers health insurance, you’ll need to submit the necessary paperwork by their internal deadline. If you’re applying online, you’ll need to verify your enrollment via HealthCare.gov and pay your first premium by the Open Enrollment deadline.
The good news is that you have some flexibility even after you’ve finished enrollment. First, you can usually change your plan up through January 15 if you decide you need to adjust or alter your coverage. For example, even if you decided your coverage on the first day of Open Enrollment but then battled an ongoing health issue immediately after, you have until January 15 to update your plan accordingly.
Additionally, most insurance companies allow a “grace period” if you miss a monthly premium payment. You’ll need to contact them directly, but you’ll still have coverage for that month as long as you pay your premium within the grace period.
A final note: Never cancel your old coverage before your new plan kicks in! You don’t want to be left with a gap of coverage in case of an emergency, or you’ll be responsible for 100% of any health costs.
5. Find Care When You Need It.
After you’ve enrolled, you’ll receive digital and physical copies of your insurance card. Keep a copy on you at all times, whether on your phone or in your wallet, and make sure everyone on your plan does the same. You may even want to give a copy to a trusted loved one in case of an emergency.
As you receive care, you’ll provide this card to your medical provider. They’ll then send information about your visit to the insurance company using standardized CPT codes for any services they administered and any additional context. The insurance company will then review your visit and provide the coverage specified in your plan. If you’re uncertain about an upcoming appointment or treatment, you can always call your provider to review your insurance plan and coverage—this will give you peace of mind on appointment day.
It generally takes about a month or two to receive an invoice from the medical provider for your outstanding fees (deductibles, procedures not covered, etc.). These fees are usually payable online via card or in the mail via check; many providers also offer payment installation plans for more expensive balances.
Sometimes, your insurance company will deny coverage—this has happened to me on more than one occasion. Try not to stress just yet! If you know your healthcare was medically necessary, you can appeal the claim and fight for coverage. You can also review the CPT codes or call your doctor to ensure they used the appropriate ones. Once, my code was incorrectly typed and a simple switch of code numbers was all I needed to reverse my denied claim.
And, if you do not have health insurance and need emergency care, you can still visit a walk-in clinic or urgent care center to receive medical treatment—they legally cannot turn you away. Explain your situation and request support with repayment plans or with applying to emergency Medicaid. If you have less urgent needs, you can also find low-cost (or sometimes free) healthcare in your community, like for the COVID vaccine, prenatal care, or substance abuse programs.
The process of picking health insurance in the United States is a tedious one, and we have a long way to go before everyone in this country has affordable or accessible healthcare. But we’re not in this process alone. Many organizations are helping make quality care available to everyone, like Planned Parenthood, RIP Medical Debt, and locally funded community centers.
Here’s to our health, community care, and quality healthcare for all (see what I did there?).
Henah Velez (she/her) is an Editor at The Good Trade. She holds a Master’s in Social Entrepreneurship and is a proud Rutgers grad. Originally from NJ, Henah’s now in Santa Barbara, CA, where she loves shopping small, hanging with her pets, or traveling. Say hi on Instagram!