What to look for in a health insurance plan

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Health insurance (also called health coverage or a health plan) helps you pay for medical care. All health insurance plans are different. Each plan costs a different amount of money and covers different services for you and members of your family. 

When choosing your insurance plan, take some time to think about your family’s medical needs for the next year. Then compare plans to find out which one is right for you. You can find plan summaries and get information about health plans for you and your children in your state’s Health Insurance Marketplace. This is an online resource set up by the Affordable Care Act that helps you find and compare health plans in your state.

Each plan in the Marketplace has a summary that includes what’s covered for you and your family. Every plan uses the same summary form, so it’s easy to compare costs and services.

How do you know what a health plan costs?

When comparing health insurance plans, look at these costs to help you decide if the plan is right for you:

  • Premium. This is the amount of money you pay each month for insurance.
  • Deductible. This is the amount of money you have to spend before the plan starts paying for your health care. For example, if you have a $500 deductible, you have to spend $500 on health care before your plan will pay. Your deductible does not include your premium.
  • Co-payment (also called co-pay). This is the amount of money you pay for each health care service, like a visit to a health care provider.
  • Maximum out-of-pocket cost or expense. This is the highest amount of money you would have to pay each year for health care services. You don’t have to pay more than this amount, even if the services you need cost more.

What health care providers do insurance plans cover?

Each health plan has a network (group) of health care providers, including doctors and hospitals. Here’s what to look for in a health plan when you’re thinking about providers:

  • Preferred providers. These providers have a contract (agreement) with a health plan to provide medical services to you at a discount. In many cases, going to a preferred provider is the least expensive way to get health care.
  • Participating providers. These are preferred providers, but they may be more expensive to see.
  • Tiered network. This means a health plan has different costs for different providers. You may have to pay more to see some providers than others.

If you or a family member already has a health care provider and you want to keep seeing them, you can find out which plans include that provider. You can still go to that provider even if they are not covered by your plan, but you may have to pay more to see them. Or if you’re pregnant and want to have your baby at a certain hospital, you can see what plans include that hospital.

You can find out about each health plan’s providers in the online Marketplace.

What health care services do insurance plans cover?

The Affordable Care Act (also called ACA) says that insurance plans have to cover certain services that you may need if you’re pregnant, thinking about getting pregnant or a new mom:

If you’re starting a family, think about the medical needs you and your family may have. When choosing an insurance plan, check to make sure that the care you need is covered. You can find out what services are covered by each health plan in the online Marketplace.

Does health insurance cover prescriptions?

All plans have to cover prescriptions, but each plan covers them differently. A prescription is an order for medicine given by a health care provider. If you use prescription medicine, you can find out what prescriptions are covered by each health plan in the online Marketplace.

More information

Centers for Disease Control and Prevention (CDC)

Show Your Love Preconception Health

Last reviewed August 2014