Is That Plan Right for You? 8 Questions to Ask Prospective Health Insurers

By Steve Dorfman

If you feel like searching for health insurance is a full-time job, or that evaluating your plan options requires an advanced degree, you’re in good company. Health insurance is really, really complicated.

The good news: health insurance consumers have far more agency than they realize. As a consumer, your first line of defense against the inscrutable is your ability to ask questions — an ability that all of us share, no matter how credulous we might seem.

Before you purchase a new health insurance policy, you’ll want to give your querying muscles plenty of exercise. These eight questions should definitely be on your list, but there are plenty more worth vocalizing too.

 1. What Does the Network Look Like?

Healthcare.gov defines “network” as “the facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.”

 

“The bigger the network, the more healthcare choice you have. But, as is so often the case, bigger doesn’t always equate to better.” — Steve Dorfman

 

Your ideal network includes the primary care providers, specialists, and hospitals that you need to achieve optimal health outcomes.

2. What Plan Types Are Available?

WebMD notes that health insurance plans come in a variety of different types. Said types are distinct from coverage levels (see question #3).

Health insurance plan types include:

  • Health maintenance organizations (HMOs), which are built around primary care providers that refer patients out to specialists as necessary. HMOs have lower paperwork requirements than some other plan types, but they’re not ideal for customers who value expansive choice.
  • Preferred provider organizations (PPOs), which offer a bit more provider choice and don’t require referrals for patients to see specialists. PPOs impose relatively high out of network costs, so you’ll want to stay in-network if at all possible — yet another reason to ask question #1.
  • Exclusive provider organizations (EPOs), which are comparable to PPOs on but one crucial point: by definition, they provide no coverage for out of network visits. If you need to venture outside your EPO’s network, you’ll pay full provide for whatever services you procure.
  • Point of service plans (POSs), which combine the simplicity of HMOs with the flexibility of PPOs.
  • Catastrophic and high-deductible plans, which provide basic coverage and impose relatively high out of pocket costs for actual health services. These plans may work well for healthy individuals, self-employed people, and those seeking to bridge employment gaps.

3. What Coverage Levels Are Available?

Now, onto the metals. Each ACA-compliant plan is assigned a metal level that roughly corresponds to the generosity of its coverage. Metal levels range from bronze, which denotes more limited coverage with higher out of pocket costs; to platinum, which denotes more generous coverage with lower out of pocket costs. Premiums increase in direct proportion to coverage.

4. Do Your Plans Meet My Healthcare Needs?

Think that platinum plan is a slam dunk? Think again. If you’re a younger, healthier individual with a limited budget, you may be better served by a more affordable plan with lower coverage levels. Before you purchase a plan, you’ll need to dive into its features and benefits to determine whether it actually meets your healthcare needs — or whether it provides too much or too little coverage.

5. How Much Can I Expect to Pay Out of Pocket?

The budgeting fun never ends. Though metal levels provide some guidance as to your expected out of pocket costs, rough estimates are rough for a reason — they’re often wrong. And not all individual insurance plans have metal levels. You won’t know for sure whether you can truly afford a health insurance plan unless you ask this question directly.

6. Will I Have Any Control Over My Out of Pocket Costs?

This is another important question for cost-conscious consumers. (Aren’t we all?) There’s a surprising amount you can do to control out of pocket costs — see this helpful roundup by Cigna, a major insurer. Not all plans allow totally free reign on the cost control front, though: you can’t get around restrictive provider networks, for instance.

7. What Benefits Are Included?

This blunt little question seems too basic to waste an insurer’s time with, but plan benefits aren’t always apparent from plan documents — even those written in plain English. If an insurer wants your business, they’ll take the time to spell out plan benefits in detail.

8. Do Your Plans Have Any Restrictions on Pre-Existing Conditions?

Non-ACA-compliant plans don’t necessarily provide coverage for people with pre-existing conditions. If you’re worried that something in your medical history could cause trouble on the underwriting front, you’ll want to get assurances before you go through the trouble of applying.

Are you in the market for health insurance? What’s the most pressing question you’d like to ask prospective health insurers?

 

Steve Dorfman is the founder and current CEO of two Florida-based firms: Simple Health and Simple Insurance Leads.