5 questions to ask when picking a health insurance plan

The United States has the highest healthcare costs in the world¹. According to the Centers for Medicare & Medicaid Services' National Health Expenditure Accounts (NHEA), U.S. health spending grew 7.2% in 2024, reaching $5.3 trillion, or $15,474 per person².

While the cost of care isn't cheap, you can make it more affordable with health insurance coverage. When you work with a health insurance company, you agree to share the cost of healthcare prices with the company in exchange for a premium. Plus, depending on your health plan type, you can access in-network providers that offer discounted rates.

If your employer doesn’t offer a group health plan, or they offer a stand-alone health reimbursement arrangement (HRA), you’ll need to shop for your own individual health insurance plan. But how do you know which plan is right for you?

In this article, we'll cover five of the most important questions to ask when picking a health insurance plan.

In this blog post, you'll learn:

• How to determine the best coverage option for your needs.
• Important factors to consider when assessing the cost of a health plan.
• Why it's important to look at each health plan's network of doctors.

1. What type of health coverage is right for you?

This is the first question you'll want to consider so you don't fall short on coverage or break the bank with out-of-pocket expenses.

Before choosing a health insurance plan, it helps to understand how different plan types work.

The most common types of networks include:

• Health maintenance organization (HMO): Usually requires you to use a network of providers and may require a referral to see a specialist.
• Preferred provider organization (PPO): Gives you more flexibility to see both in-network and out-of-network providers, usually without referrals.
• Exclusive provider organization (EPO): Covers care only from in-network providers except in emergencies, but typically doesn't require specialist referrals.
• Point of service (POS): POS plans combine features of HMO and PPO plans. You may need a referral for specialists, but you can generally receive out-of-network care at a higher cost.

The right plan type for you depends on your healthcare needs, preferred doctors, budget, and how much flexibility you want when choosing providers.

Eric Testa, Benefits Advisor at PeopleKeep, recommends looking ahead at your expected healthcare needs when choosing a plan.

"If you've generally been healthy and don't anticipate significant medical expenses, a lower-premium, higher-deductible plan may make sense," Testa said. "But if you know you'll have surgery or other high-cost care coming up, a higher-premium plan with a lower deductible and lower out-of-pocket maximum could save you money overall."

PeopleKeep and Remodel Health’s 2026 National ICHRA Report found that most of our customers with an individual coverage HRA (ICHRA) enrolled in an HMO plan (45%), followed by an EPO plan (34%).

2. What does the health plan cover?

Before the Affordable Care Act (ACA), health insurance plans varied significantly in their coverage, with no standardized requirements for the medical services they included. For instance, certain plans might exclude coverage for maternity care, preventive care, mental health treatments, or prescription drugs.

That changed in 2014 when the ACA mandated that all Marketplace individual and small group health insurance policies must cover at least³ the essential health benefits.

The ACA considers the following ten benefits essential:

• Emergency services
• Hospitalization
• Lab services
• Maternity and newborn care
• Mental health care and substance abuse treatment
• Outpatient care (medical services you receive outside of a hospital)
• Pediatric services, including dental and vision care
• Prescription medications
• Preventive services (such as immunizations, check-ups, and screenings like mammograms) and management of chronic conditions such as diabetes
• Rehabilitation services

The insurance rules for coverage large employers provide (as defined by the ACA as having 50 or more full-time equivalent employees) are slightly different. Still, most will cover the same set of benefits. If you're selecting from plans offered by a large employer and are unsure what the plans cover, ask your employer for the Summary of Benefits and Coverage⁴ (SBC). This standard form states which products and services the coverage includes.

You can always see what individual health plans on the public and private exchanges cover by downloading the SBC or requesting it.

3. How much does the health plan cost?

Testa recommends looking closely at the costs you'll encounter most often, including prescription drug costs and copays for urgent care and specialist visits.

Let's look at a few categories of medical expenses to help you determine how much you'll end up paying for your plan.

Premium

Your health insurance premium is the amount you'll pay to maintain your coverage. You’ll typically pay this monthly. This monthly payment won't change throughout your plan year so that you can budget for it each month. Just like a monthly car insurance payment, you'll pay your premium even if you don't use your insurance to cover anything that month.

If you have a stand-alone health reimbursement arrangement (HRA) from your employer, such as an individual coverage HRA (ICHRA) or qualified small employer HRA (QSEHRA), your employer can reimburse you for your qualifying individual health insurance premiums.

Deductible

The deductible is the amount you'll pay for covered services before your health insurance pays for anything. For example, if you have a $3,000 deductible, you'll have to pay $3,000 on your own before your insurance starts covering your bills. Generally speaking, plans with higher deductibles have lower premiums and vice versa.

"People often overlook the phrase 'after deductible' on their SBC. It's usually ideal to find a plan with as many fixed copay amounts as opposed to plans that make you reach your deductible before the carrier offers support," Testa said.

However, under the ACA, individual health plans must cover essential health benefits regardless of whether you've met your deductible.

Copay

A copay, or copayment, is a flat dollar amount you'll pay your medical provider for a covered service. For example, you may have to pay a $20 copayment for each covered doctor visit to a primary care provider (PCP) or $10 for each generic prescription you get filled. Copayments vary from plan to plan but generally fall between $10 and $50.

If you take prescription medications regularly, Testa said it's also important to check how each plan covers them.

Coinsurance

Coinsurance is the percentage of allowed charges for covered services you must pay after meeting your deductible. For example, if your plan has 30% coinsurance for hospitalization, your health insurer covers 70% of the charges for a covered hospitalization, leaving you responsible for the remaining 30%.

Out-of-pocket maximum

An out-of-pocket maximum is the maximum amount you'll pay for medical expenses during a benefit period (for example, over a year).

The out-of-pocket maximum never includes your premium, balance-billed charges, or services your health insurance plan doesn't cover. The out-of-pocket maximum varies by plan and can include copayments, deductibles, and coinsurance.

Once you have paid your out-of-pocket maximum for the year, your insurance company will pay the total amount of your covered medical expenses for the rest of the period.

Given the different prices within a single plan, comparing plans and their overall costs can be tricky. That's why the state and federal marketplaces display individual and small group plans in standardized “metallic tiers of coverage" ranging from Bronze to Platinum, with various combinations of premiums and out-of-pocket costs.

For example, a Platinum plan generally has the highest monthly premium, but you'll pay the least out of pocket when you receive medical care. This is a good option if you require routine care, such as for chronic illnesses. With these types of plans, your insurance company agrees to pay 90% of your medical expenses, and you agree to pay the remaining 10%.

With Bronze, Silver, and Gold plans, you'll pay lower monthly premiums but pay more when you receive medical care.

This chart covers the basic structure of those options, including the 2026 average monthly premiums from data collected by KFF ³ :

Not sure which plan is right for you? If your employer offers an HRA through PeopleKeep, you have access to a complimentary benefits advisement to help you understand your options and choose coverage that fits your needs.

4. Can you keep your current doctor?

Every health insurance plan has a network of providers that includes primary care physicians, specialists, hospitals, laboratories, imaging centers, pharmacies, and more. Each health insurer has contracts with these types of medical providers that agree to provide healthcare services to plan members at a specific cost.

If your doctor isn't in your plan's network, your insurance carrier may not cover the bill. In other cases, they may require you to pay a higher share of the medical cost. So, if you have a few favorite doctors you want to continue seeing, make sure they're included in the plan's provider network.

If you're shopping for health insurance on your own, review the plan's provider directory before you purchase the plan. If you're looking at health insurance options through your employer, you can get provider lists from participating health insurance companies. You can also reach out to the company's employee benefits department.

In either case, you should call your providers directly to confirm that they accept the insurance plan you’re considering.

5. Where will you have coverage?

Accidents happen. One day, you may need emergency medical care while you're away from home. Maybe you catch a cold while you're away on vacation. Either way, what happens when you're far from your in-network doctors?

To ensure you're fully covered, check how the plans work when you're out of state or traveling abroad. Most plans cover visits to emergency rooms and urgent care centers anywhere in the United States, and some offer emergency coverage throughout North America, but it's always good to double-check the details.

It's also helpful to know whether a plan offers telemedicine or virtual visits, so you can easily connect with a doctor using your mobile device.

Conclusion

Choosing your own health insurance coverage can seem daunting at first, but by asking yourself these five simple questions, you'll be well on your way to finding a policy that meets the needs of you and your family. Whether you frequently require medical care or see a doctor annually, there's a plan tailored to your specific cost and coverage preferences.

This article was originally published on October 31, 2013. It was last updated on August 31, 2026.

References

1. HST: How does health spending in the U.S. compare to other countries?
2. Centers for Medicare & Medicaid Services
3. Healthcare.gov: Health benefits & coverage
4. Healthcare.gov: Health insurance rights & protections
5. KFF: Average Monthly Marketplace Premiums by Metal Tier