Choosing the right health insurance plan can feel overwhelming, especially if you’re doing it for the first time. With various options, coverage levels, premiums, and confusing terminology, it’s easy to pick a plan that might not fit your needs.
To help you make a well-informed decision, here are the most important questions you should ask before purchasing health insurance—whether through an employer, government marketplace, or private insurer.
1. What Types of Plans Are Available to Me?
Health insurance plans come in different types, each with its own rules and costs. The most common are:
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HMO (Health Maintenance Organization): Requires you to use in-network doctors and get referrals to see specialists.
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PPO (Preferred Provider Organization): Offers more flexibility in choosing doctors and doesn’t require referrals.
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EPO (Exclusive Provider Organization): Covers only in-network services but may not need referrals.
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POS (Point of Service): Combines elements of HMO and PPO.
Each has its own pros and cons. HealthCare.gov provides a detailed breakdown of these plan types.
2. What’s the Total Cost of the Plan?
Your monthly premium is just one piece of the puzzle. You should also consider:
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Deductibles – how much you pay out-of-pocket before insurance kicks in.
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Copayments and Coinsurance – your share of costs for specific services.
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Out-of-pocket maximum – the limit you’ll pay in a year before your plan covers 100%.
Use the Kaiser Family Foundation Health Insurance Calculator to estimate your total yearly costs.
3. Are My Preferred Doctors and Hospitals in the Network?
If you already have doctors you trust, make sure they are part of the insurance provider’s network. Out-of-network care usually costs more or may not be covered at all.
Many insurers offer a provider lookup tool on their website to check if your healthcare providers are included.
4. Does the Plan Cover My Medications?
Prescription drug coverage varies greatly between plans. You’ll want to:
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Review the plan’s formulary (list of covered drugs)
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Check if your medications require prior authorization
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See if there’s tiered pricing, which affects how much you pay for generic vs. brand-name drugs
If you have chronic conditions requiring regular medications, this is a critical factor.
5. What Services Are Covered Beyond Basic Care?
All ACA-compliant plans cover essential health benefits like emergency care, maternity, and mental health services. But there can be differences in how much and how often certain services are covered.
Ask about:
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Preventive care
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Rehabilitation
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Vision and dental (often not included in adult plans)
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Mental health therapy sessions
Explore this HealthCare.gov guide to covered services to learn more.
6. What Are the Rules for Seeing Specialists?
Some plans require a referral from your primary care provider (PCP) before seeing a specialist. Others let you make appointments directly.
If you have a condition that needs ongoing specialist care—like asthma, diabetes, or back pain—this policy can make a big difference in how quickly you get help.
7. How Are Emergency Services Handled?
Emergencies can happen anywhere. It’s essential to know:
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Will your plan cover out-of-network emergency care?
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Are there restrictions on urgent care clinics?
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What does the plan define as an emergency?
Confirm with your insurer how they handle emergency claims, especially when you’re traveling or out of state.
8. Are There Any Waiting Periods?
Some plans have waiting periods for coverage on:
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Pre-existing conditions
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Maternity benefits
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Dental or vision services
If you’re switching plans or enrolling for the first time, find out if any services are delayed in coverage.
9. What Happens If I Travel or Move?
Does your plan provide coverage while traveling nationally or internationally?
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Some national plans offer a broader network across state lines
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Others may restrict you to regional care
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If you move, your plan might not be valid anymore
Check whether the policy is flexible enough for your lifestyle.
10. What Tools or Resources Does the Insurer Offer?
Modern health insurers often provide:
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Mobile apps to track claims or find doctors
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24/7 nurse hotlines
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Health and wellness discounts
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Telemedicine services
These added features can improve your experience and help you make the most of your coverage.
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Final Thoughts
Health insurance isn’t one-size-fits-all. The right policy depends on your budget, lifestyle, medical needs, and preferences. Asking the right questions helps you compare plans effectively and avoid surprises when you need care.
Before committing, take advantage of online comparison tools and speak with a licensed insurance advisor if needed.
Still confused about health insurance terms? Start with this glossary of health coverage terms from HealthCare.gov.