Nov. 1 isn’t a holiday on most calendars, but it’s one of the most important dates of the year. It marks the beginning of open enrollment — the period when people can sign up for new health insurance plans in the health insurance marketplace created by the Affordable Care Act (ACA). Many private employers hold their annual enrollment periods for health care plans at the same time, so all over the country, millions of people begin comparing insurance policies and trying to choose the right plan for themselves and their families.
It can be a complicated process. There are many factors to consider when choosing a health insurance plan, including the monthly premium, the out-of-pocket costs, and the network of available providers, such as doctors and hospitals. Even experts sometimes find it hard to sort it all out. Zachary Tracer, a health care editor at Business Insider who has written about health care for years — and is married to a doctor — says he still “had a tough time” figuring out which of the four plans his new employer offered would be best for him.
To make sense of what even the pros find confusing, you need to tackle the job systematically. Work your way through step by step, beginning with a grounding in the basics of how health insurance and health insurance marketplaces work. From there, you can move on to comparing different types of plans, costs, and coverage.
Step 1: Understand Health Insurance Costs
All health insurance plans work on the same basic principle. You pay a monthly fee, called a premium, to the insurance company. It pools the money from all its customers’ premiums and uses it to pay a portion of their health care costs as needed. As long as the amount it pays out is less than it collects in premiums, the company makes a profit.
To make sure their costs stay below their earnings, health insurance plans require their customers to cover some of their own care costs. In addition to your monthly premium, your costs can include:
- Deductible. Your health insurance plan’s deductible is an amount you must pay entirely out of your own pocket before your insurance starts to pick up the tab. For example, if your plan’s deductible is $1,000, you must pay 100% of your medical expenses until your bills total $1,000. After that, your health coverage kicks in.
- Coinsurance. Even after you reach your deductible, you typically have to pay a portion of your health care costs. In some cases, the insurance company pays a percentage of each medical bill, and you pay the rest. Your share is called coinsurance. For example, if you have a plan with 20% coinsurance and receive a $200 bill from the doctor, you pay $40 and the company pays the other $160.
- Copayments. Instead of coinsurance, some companies charge you a fixed amount called a copayment, or copay, for any covered medical service. For example, a plan might require a $25 copayment for a visit to your primary care physician, a $50 copay to see a specialist, and a $10 copay on prescription drugs. In most cases, you pay this amount upfront when you receive care, and the rest of the bill goes to the insurer.
There’s one more figure that’s critical to consider: your out-of-pocket maximum. It’s the highest total amount you can spend on all your health care costs in a year — deductibles, copayments, and coinsurance. Once you reach this limit, your insurance company picks up all your care costs for the rest of the year. Premiums don’t count toward this limit, and neither do services not covered by your insurance plan.
For example, let’s say that at the beginning of your plan year, you find out you need a knee-replacement surgery that costs $30,000. Your plan has a $1,500 deductible, 20% coinsurance, and a $2,200 out-of-pocket maximum. After paying your deductible, your 20% coinsurance totals $5,700. But because your out-of-pocket maximum is set at $2,200, you pay only an additional $700. The insurance company covers the rest.
Step 2: Find Your Insurance Marketplace
The first step in shopping for a health plan is figuring out where you need to shop and when. The marketplace you use determines your health insurance options: types of plan, levels of coverage, and costs. Places to look for health coverage include:
Many Americans who have health insurance get it from an employer. Some workplaces offer only one health plan, while others have several plans to choose from, sometimes from multiple health insurance companies. If you’re self-employed or your job doesn’t provide health benefits, you may be able to get coverage from your spouse’s or partner’s employer. If you’re age 25 or younger, you can get coverage as a dependent on a parent’s plan, even if you no longer live with your parents.
You’re not actually required to sign up for a workplace health plan just because one is available to you. You’re allowed to shop around for a better deal on federal, state, or private health marketplaces.
However, for most people, an employer’s plan is the cheapest way to get health coverage. For one thing, insurance premiums for workplace plans tend to be lower than those for individuals. Also, most businesses reduce the cost still more by picking up part of the tab — at least for their employees, and sometimes for their spouses and children.
The Federal Health Marketplace
If you can’t get health coverage from an employer, the first place to look for it is the federal health insurance marketplace at HealthCare.gov. Through this site, the government makes plans from private insurance companies available to the public. The marketplace can also help you figure out whether you qualify for subsidies to lower your insurance premiums’ cost. If you do, it automatically applies the subsidy to any plan you purchase. Alternatively, it can tell you whether you or your family members qualify for other government plans like Medicaid or the Children’s Health Insurance Program (CHIP).
When HealthCare.gov debuted in 2013, the site was notoriously slow and unreliable. However, according to NPR, the current version of the site looks and works much better. New features introduced in 2019 make it easier than ever to apply and to compare different plans.
In most cases, it’s only possible to shop for a marketplace health plan during the open enrollment period, which runs from Nov. 1 to Dec. 15 every year. However, you can sign up for a marketplace plan at other times if you’ve just gone through a life event that dramatically changed your circumstances. Examples include losing your job (and your health coverage with it), getting married, or having a baby.
State Health Marketplaces
Although most states participate in the federal health insurance marketplace, 14 states and the District of Columbia run their own separate health exchanges. These marketplaces sell health plans for individuals, families, and sometimes small businesses. Some states have longer enrollment periods than the federal health exchange, so you might have extra time to enroll depending on where you live.
States that have separate health marketplaces include:
- New Jersey
- New York
- Rhode Island
If you live in one of these states, visiting HealthCare.gov will automatically redirect you to the website for your state’s health exchange.
If you’re a senior citizen, your best bet for coverage outside the workplace is Medicare. This plan is available to Americans who are over 65 or disabled — even those who are still working.
Medicare isn’t just a single plan with the same coverage for everyone. Medicare customers can choose traditional Medicare, which covers hospitalization (Part A) and doctor visits (Part B), and add a separate plan to cover prescription drug costs (Part D). They can also choose to add a Medicare supplement insurance policy, also known as Medigap, to help cover out-of-pocket costs.
Alternatively, customers can opt for a Medicare Advantage plan. It provides all-in-one coverage for Parts A, B, and usually D. Most Medicare Advantage plans also include other benefits, such as dental or vision coverage. You can review your choices and costs for all these types of plans at Medicare.gov. Open enrollment for all plans starts on Oct. 15.
Military Health Plans
Members of the United States military and their families get full health coverage through Tricare. This program includes several plans. Depending on where they serve, active-duty military members must sign up for Tricare Prime, Tricare Prime Remote, Tricare Prime Overseas, or Tricare Prime Remote Overseas. Their family members can choose from one of these plans or another plan available to military families, such as Tricare Select or Tricare Young Adult. The Tricare website has tools to help you find the right plan for you and your family.
Retired service members and their families can also purchase health insurance plans through the Tricare site. Veterans who are not enrolled in Tricare can apply for the veteran health care program through VA.gov. With certain exceptions, this program is open to people who served at least two years in the armed forces. The VA website can also help spouses and dependents of veterans determine whether they qualify for care under various government programs.
Other Sources of Insurance
These markets are the main places to shop for health insurance, but they’re not the only ones. For instance, you can also choose to buy your care directly from an insurer, shop on a private exchange, or shop through an insurance agent. One advantage of shopping privately is that you can sign up for a plan at any time rather than waiting for the open enrollment period.
If you have recently lost your job but want to keep your old health care plan, you can do this through the Consolidated Omnibus Budget Reconciliation Act (commonly known as COBRA). However, you must pay for the full cost of the plan yourself without help from your employer. In most cases, a plan purchased through the health insurance marketplace will be cheaper, especially if you qualify for subsidies.
Step 3: Understand Your Options
Once you’ve figured out where you need to shop for insurance, you can start looking at different plans. However, doing so can leave you feeling even more confused. There are many types of health plans with an alphabet soup of names, such as HMO, PPO, and POS, all of which provide different amounts and types of coverage.
To understand which type of plan is right for you, you first have to understand what each one covers and which health care providers it allows you to see.
This type of plan is just what it sounds like: Your insurance company pays your health care provider a fee for each service you receive, from an office visit to a surgical procedure. You can receive medical care whenever and wherever you want, with no prior approval or referral needed.
The downside of this type of plan is that it comes with much higher monthly premiums than other plans. Also, these plans sometimes require you to pay the full cost of medical services upfront, then submit a claim to your insurance company to get reimbursed. These costly plans are not generally available in the health insurance marketplace.
HMOs & EPOs
Health maintenance organizations, or HMO plans, require you to receive care only from providers within the plan’s network. Out-of-network care is covered only in emergencies.
HMO plans typically focus on preventive care and wellness. They require you to choose a primary care physician (PCP), who coordinates all your care. You must see your PCP first for any problem, and they determine whether you need to see a specialist. If you do, the PCP provides a referral to a doctor in the HMO network.
HMOs are the most restrictive type of health plan. However, they balance that by offering low out-of-pocket costs for care.
An exclusive provider organization (EPO) is like an HMO but with less of a focus on primary care. You must still use only in-network providers, except in emergencies. However, you’re allowed to see any doctor within the network without a referral.
PPOs & POS Plans
With a preferred provider organization (PPO), you pay less for care from providers within the network, but you still receive some coverage for out-of-network care. That allows you to see any doctor you choose without a referral. PPOs generally have higher premiums and out-of-pocket costs than HMOs and EPOs.
A point-of-service (POS) plan is like a PPO but with a stronger focus on primary care. You must choose a primary care physician, and your PCP must provide referrals for any other provider you visit.
High-Deductible Health Plans
A high-deductible health plan, or HDHP, is technically not a separate type of plan. It can be any of the types listed here, but it also comes with a high deductible you must cover out of pocket. Because they keep the insurance company’s expenses down, these plans typically have very low premiums.
Another advantage of an HDHP is that you can pair it with a health savings account (HSA). An HSA is a special savings plan you can use to pay for health care costs with pretax dollars. Some individuals offer HSAs to their employees. If yours doesn’t, you can purchase one from a provider such as Lively.
However, not every plan with a high deductible qualifies as an HDHP. You must look specifically for plans labeled “HSA-eligible.” According to the IRS, for the year 2019, an HDHP had to have an annual deductible of at least $1,350 for a person and $2,700 for a family. However, it also had to limit out-of-pocket expenses (including the deductible) to $6,750 for a single person and $13,500 for a family.
Levels of Coverage
There are two ways for an insurance company to make a profit. First, it can sell you a plan with low premiums that requires you to cover more of your care costs through deductibles and coinsurance. Alternatively, it can charge you a higher premium for a plan with lower deductibles and coinsurance.
Public health exchanges make it easy to sort out health care plans with high premiums and coverage from those with lower premiums and less coverage. They sort the majority of plans into four tiers: bronze, silver, gold, and platinum. The higher-tier gold and platinum plans charge higher monthly premiums and cover more of your medical expenses. The lower-tier bronze and silver plans have lower premiums and higher out-of-pocket costs.
There’s one other type of plan available in the health insurance marketplace: catastrophic health plans. These plans have very low monthly premiums and very high deductibles — $8,150 for the year 2020. Catastrophic plans are available only to people under age 30 or people who can show they can’t afford one of the higher-priced metal plans. Also, you can’t use premium tax credits to help pay for these plans, so if you qualify for a tax credit, a subsidized bronze or silver plan is probably cheaper.
Although some workplace health insurance plans also use these metal tiers as identifiers, that isn’t a requirement. If the plans available from your employer aren’t sorted by tier, it’s a bit tougher to compare them. You have to look at each plan’s details separately to figure out how much its premium costs balance out against the level of coverage it provides.
Coverage for Other Health Care Costs
Note that even the highest-tier plans don’t necessarily cover all types of medical costs. Under the Affordable Care Act, also known as Obamacare, all plans are required to cover essential health benefits, such as hospitalization, preventive care, prescription drugs, and mental health. However, costs like dental care and vision care are not always covered. You have to check the description of each individual plan to see if it includes these benefits.
If the plan you choose doesn’t cover these costs, you can consider shopping for a separate dental insurance or vision care plan to help with these expenses. However, these plans have their own monthly premiums, so you have to factor in that expense when comparing costs.
One expense health insurance plans don’t cover is the cost of long-term care — for example, in a nursing home or assisted living facility. To protect yourself from this cost, you must purchase a separate long-term care insurance policy. The premiums for this type of insurance depend on your age and health at the time you first apply for the policy. According to the American Association for Long-Term Care Insurance, the best time for most people to apply is in their mid-50s.
Step 4: Compare Available Plans
Now that you have a good understanding of health insurance marketplaces, plan types, coverage, and costs, it’s time to start comparing specific plans. Even if you’re happy with your current health insurance coverage, it’s worth shopping around to see what else is available. For one thing, it’s possible the cost or coverage of your current plan has changed for the upcoming year. Also, there may be better options available to you now that weren’t on the market last time you checked.
Look at the list of plans available from your employer or the public marketplace, and see how they stack up in the areas that count.
All ACA-approved plans have to cover 10 types of essential care. However, only some plans cover services considered nonessential, such as acupuncture, chiropractic care, orthotics, or hearing aids. If you require any type of care that’s not on the essential list, look for a plan that covers it. This information should appear in the plan’s summary of benefits, which you can view in most online marketplaces.
Note that even if your plan covers a nonessential benefit, it may have a lifetime benefit maximum — a cap on the amount it will pay out for this type of care over your lifetime. Check the lifetime benefit maximum for any services you use, and consider whether it’s likely to be enough to meet your needs.
Also, while all plans must cover prescription drugs, not all plans cover the same drugs. If you’re taking a particular medicine, you can enter it on HealthCare.gov to see only plans that cover it.
If you have a doctor you really like, look for a health plan that includes that doctor in the plan network. Each plan should include a provider directory you can check to see which doctors the network includes. You can also enter the name of a preferred provider, such as a doctor or hospital, when browsing on HealthCare.gov. The site will then show you only plans that provider accepts.
Note that even if your doctor is listed as an in-network provider, that doesn’t mean you’ll pay the lowest price when seeing them. Some networks are “tiered,” so you pay more to see doctors in the network’s outer tier than those in the inner tier. If possible, choose a plan that has your favorite doctor in the inner tier.
If you don’t have a preferred doctor right now, look for a plan with a large network, which will give you more providers to choose from. That’s especially crucial if you live in a rural area or a sparsely populated suburb since it increases the chances of finding a doctor in your area. Look for a plan that includes nearby doctors in the network so you don’t have to drive an hour for every appointment.
Type of Plan
Along with the network itself, consider how much coverage you have for seeing a doctor outside it. If you travel a lot or have complicated health problems that require a lot of specialist visits, you might need to see out-of-network doctors fairly often. In that case, you’re better off with a PPO or POS plan that lets you see any doctor you choose. On the other hand, if you hardly ever see any doctor other than your primary care physician, an HMO or EPO could be a better choice for keeping your out-of-pocket costs low.
A lower-tier bronze or silver plan makes most sense if you’re young and reasonably healthy. Since you’re not likely to need a lot of care, you won’t have to pay high deductibles or coinsurance, so it’s more important to keep your premiums low. If you’re older or in poor health, it makes more sense to opt for a higher-tier gold or platinum plan that charges higher premiums but limits your out-of-pocket costs for care.
Some health insurance plans are better than others. That’s a given. To help you compare them, HealthCare.gov offers quality ratings on all its marketplace health insurance plans. Each plan receives an overall quality rating of 1 to 5 stars (5 is the highest rating) based on:
- Member Experience: Members’ satisfaction with their doctors, care, and the ease of getting services
- Medical Care: An evaluation of how well providers in the plan’s network keep their patients healthy by providing health screenings and vaccinations, supplying basic care, and monitoring patients’ conditions
- Plan Administration: How well the plan is run, including customer service, access to information, and appropriateness of the tests and treatments ordered by network doctors
Some plans don’t have star ratings because they’re new or have low enrollment. Don’t take the absence of stars as a sign of poor quality.
When you’re shopping for care from your workplace or a private network, comparing plans is harder. But you can check plan ratings from the National Committee for Quality Assurance. This nonprofit has rated over 1,000 health care plans based on customer satisfaction and outcomes for preventing and treating disease.
Step 5: Compare Total Costs
You may find there’s only one available health plan that’s really acceptable to you. However, if you still have several options to choose from, there’s one more critical factor to consider: the cost. That means not just the monthly premium but the total cost of the plan over a whole year, including both premiums and out-of-pocket costs.
That can be hard to estimate since you don’t know what your medical expenses will be in the next year. However, there’s a tool on HealthCare.gov and some state marketplaces to make it easier. The site asks you whether health care usage for each family member is typically high, medium, or low. Then it shows you an estimated total yearly cost for each available plan based on its deductible and copays.
If you’re shopping in a health care marketplace that doesn’t have this feature, you can estimate your medical expenses based on your overall health and habits. If you are young and in good health, you probably won’t need to see a doctor often, so your out-of-pocket costs are likely to be low. However, they could be much higher if:
- You make frequent visits to a PCP, a specialist, or the emergency room
- You take expensive or brand-name medications regularly
- You have young children or are expecting a baby
- You have a planned surgery scheduled soon
- You have a chronic condition such as cancer or diabetes
If this seems too hard to figure out, try this shortcut: Just add up the annual premiums and out-of-pocket maximum for each plan. That’s the most you could possibly have to pay for your care within a given year. If that total is more than you could afford to pay without being driven into bankruptcy, you know you need a plan with more coverage.
As you compare costs, watch out for plans that seem too good to be true. Louise Norris, a health insurance broker interviewed by NPR, warns that some plans advertised online aren’t ACA-compliant and don’t provide all the types of essential health coverage required under the law. And even on the public marketplaces, some plans that look very cheap turn out to have extremely high deductibles or copays, such as $1,000 per day for a hospital stay.
Step 6: Choose the Right Plan for Your Needs
Once you’ve reviewed all your health insurance plan options and their costs, making your final decision becomes simple. The right health insurance plan for you is the one that meets your needs for the lowest cost. All you have to do is sign up — and remember to cancel your old plan so you don’t end up paying two sets of premiums.
If you’re still having trouble choosing the right plan or signing up for it, talk to a health insurance assister. These are individuals trained to help people apply for and enroll in subsidized health plans and apply for federal programs like Medicaid and CHIP. Their service is free, and their advice is fair and impartial. To find a health insurance assister in your area, visit the Find Local Help page on HealthCare.gov.
Alternatives to Traditional Health Insurance
Sometimes, it’s just not possible to find a plan that meets all your needs and still fits your budget. For instance, some people can’t find affordable care for their family because of the Obamacare family glitch, which makes family members ineligible for subsidized plans as long as the family’s primary breadwinner has access to an affordable plan at work. Others fall into the Medicaid coverage gap, which bars people from receiving health care subsidies if their income is less than 100% of the federal poverty level — even if it’s still too much to qualify for Medicaid in the state where they live.
If you can’t find a plan in your price range, some alternatives can help you cover some of your health care costs, at least temporarily. These aren’t true health insurance plans that can protect you from catastrophic medical costs, but they’re better than nothing.
Although they have “insurance” in the name, short-term insurance plans found on eHealthInsurance.com are fundamentally different from the ACA-compliant health plans sold in the health insurance marketplace. Differences between the two include:
- Term Length. Short-term plans can only provide coverage for up to 364 days. Some are even shorter, requiring renewal after a few months.
- Benefits. Short-term plans don’t have to cover all the essential benefits required by ACA-compliant plans. Most of them provide no coverage for routine care, mental health care, or prescription drugs. Also, unlike ACA-compliant plans, they can deny coverage for preexisting conditions (health problems you had before signing up).
- Out-of-Pocket Costs. Short-term plans typically have very high deductibles — often $10,000 or more. They also have no out-of-pocket maximum. In fact, most of them have the opposite: a cap on how much the insurer will pay for your care in a given year or over your lifetime. Thus, they don’t protect you from catastrophic medical bills.
- Premium Costs. Because they provide such limited coverage, short-term plans charge very low premiums. According to HealthInsurance.org, a family of four in Wyoming could pay as little as $200 per month for a short-term plan as opposed to over $2,000 per month for the cheapest bronze-level plan. However, these cheap plans do not qualify for premium tax credits, so they could cost more than a subsidized plan that’s ACA-compliant.
- Availability. You can sign up for a short-term plan at any time rather than having to wait for open enrollment. However, these plans aren’t available everywhere. Eleven states (listed at HealthInsurance.org) have either banned them or imposed regulations that make it unprofitable for insurers to sell them.
Health Care Sharing Ministries
Health care sharing ministries (HCSMs), also called health-share plans, aren’t really insurance. Instead, they’re faith-based cooperative programs in which members agree to pay a share of other members’ medical bills. Each member pays a monthly “share,” similar to the premium for a health plan, and the HCSM pools the money to cover health expenses. HCSMs include Medi-Share, Christian Healthcare Ministries, Liberty HealthShare, and Samaritan Ministries.
For people who don’t qualify for tax credits, HCSMs charge much lower monthly premiums than regular insurance. A family of four could get coverage for as little as $300 per month compared to $1,955 for an ACA-compliant health plan without subsidies.
However, these plans provide much less coverage for the cost. For instance, they typically don’t cover:
- Preexisting conditions — a term they often define so broadly you can’t get coverage for any health problem you’ve ever had before
- Mental health care or substance abuse treatment
- Any prescription drug required for more than a few months
- Preventive care like checkups, immunizations, and routine health screenings
Because health-share plans are not insurance, you can’t use them with an HSA or deduct their premiums as a medical expense on your taxes. Also, many providers don’t accept HCSM coverage, so they require you to pay your bills upfront. You can submit a claim to the HCSM for reimbursement, but this can involve vast amounts of paperwork and delays of several months.
There’s one more significant problem with relying on HCSMs for coverage: a health-share agreement is not a legally binding contract. That means you have no legal guarantee the program will keep its promises. If it doesn’t, the only way to recover your money is a lawsuit — not a great option for someone on a tight budget.
Direct Primary Care
Direct primary care, also called concierge medicine, is another way to get access to health care for a flat fee. With this arrangement, you pay an annual retainer to your primary care physician in exchange for unlimited in-office care. That includes routine visits, lab tests, and sometimes simple diagnostic tests, such as X-rays. However, you must pay out of pocket for any treatment received outside your doctor’s office, such as specialist visits, hospital care, or prescription drugs.
Direct primary care makes it easy to see your doctor whenever you want. You don’t have to wait months for an appointment only to be rushed in and out of the office in only 10 minutes.
However, it’s not always cheaper than regular health insurance. According to Stat, a medical news source, monthly fees for direct primary care typically range from $50 to $200. On top of that, you usually need a barebones insurance plan, such as an HDHP or catastrophic insurance, to cover your out-of-office costs. The total cost could end up being more than an ACA-compliant plan, especially if you qualify for a tax credit.
There’s one more problem with direct primary care: Most U.S. doctors don’t offer it as an option for their patients. According to the Direct Primary Care Coalition, there are only 620 concierge medical practices in the country.
Despite the changes made by the ACA, health insurance in the U.S. remains expensive. According to the Economic Policy Institute, American families with earnings in the bottom 90% paid an average of 15% of their income for workplace insurance coverage in 2016. And for the millions of Americans caught in the Medicaid coverage gap or the family glitch, subsidies can’t help.
However, as expensive as insurance is, going without it can cost even more. Without it, a single unexpected health problem could cost you thousands of dollars, driving you deep into debt or even bankruptcy.
If you’re in good health, insurance can seem like a waste of money. After all, you’re paying a premium month after month for coverage you don’t even use.
But it makes more sense to think of health insurance like car insurance — something you pay for, hoping you’ll never have to use it. It’s much better to have it and not need it than to need it and not have it. The money you spend on unused coverage isn’t wasted. It’s the price you pay for peace of mind.