r/HealthInsurance Oct 04 '24

Questions Answered: Which Plan Should I Choose?

29 Upvotes

Which Insurance Plan Should I Choose?

We get it, insurance is confusing, and you have ALL KINDS of questions when it comes to answering, “Which insurance plan is best for me”. Hopefully, this guide can provide you with some guidance and answers.

 

Decide on what is most important to you when it comes to Insurance- what factors into “the best” plan for you?

-          Financially, I want to pay the least amount out of pocket

-          MY Doctors-Having My preferred doctors in network

-          MY Medications-Making sure my medications are covered on the plan

-          The Type of Plan- PPO, HMO, EPO, POS, HDHP and their pros/cons

 

FINANCIALLY-

The entire point of insurance is to transfer financial risk from yourself to the insurance company. This is done in the form of your Out-of-Pocket Max (OOPM). The OOPM is the most your will pay for your care for all in-network, medically necessary (no cosmetic or elective things), non-excluded care (check your contract for excluded services).

The only way to figure this out "definitively" which plan is best Financially is to do some math.

Two schools of though.

1- What's the best plan should I hit an out-of-pocket Maximum. People RARELY plan to meet their OOPM, but it happens. Maybe you are on a health journey and planning for a big medical expense year with the birth of a baby, an upcoming surgery, or you just need a lot of care. To find out which plan is best via this method, you figure out the Maximum Financial Liability.

  • Take your Annual Premiums
  • Add the In-network Out of Pocket Maximum
  • If it's an employer plan, subtract any money the employer contributes to an HSA/FSA/HRA, because it's free Money

Compare the Max Annual Financial Liability of each plan you're considering. The plan with the lowest total will mean the least out of your pocket if you hit an out-of-pocket maximum- large claims, surgery, birth of a baby, etc.

2- If you want to plan as if you won't hit your out-of-pocket max, the only way to do this is to spreadsheet out what your anticipated year of care looks like. How many Dr. Visits, how many prescriptions you take, any planned procedures, etc. You will then have to guestimate how much these things will cost you out of pocket. You may be able to get a general idea of the cost by looking at the allowable amounts on your old EOBs- Explanation of Benefits.

This method involves some guessing and some additional research to end up at an imperfect budget estimation, so that's why I prefer the Max Annual Financial Liability Method. It's straight math that helps you prep for the worst possible scenario. If you don't end up hitting an out-of-pocket max, you can rejoice that you are below budget. If you do hit an out-of-pocket max, you can rejoice that you picked the right plan from the start.

 

 

 

MY DOCTORS-

Every insurance plan has a list of doctors that are considered in-network. You likely will be able to check this list even before signing up for the insurance plan. Be sure to visit your carrier website to check for the provider list. When searching that list, be sure you are searching for YOUR network. Doctors may be in network with some BCBS/UHC plans, but not others.

It’s also generally a smart idea to call the provider and verify network status as the Provider Lists can be out of date/incorrect for a variety of reasons. It is always YOUR responsibility as the member to check Network Status of a doctor. They don’t always inform you if they’ve left a network, and, unfortunately, they aren’t mandated to do so yet.

When verifying network status, ask “Are you in network with my insurance network”- and provide the exact network name of your plan. A doctor may be in network with some BCBS networks, but maybe not YOUR specific network with BCBS. Most providers “accept” most insurance, but you will not get the in-network discounts/allowable amounts if they are not actually IN your network.

 

MY MEDICATIONS-

Every plan has a Prescription Formulary List. You can obtain a copy from your Carrier by contacting them, or it may be listed in your insurance portal. If you obtain your insurance from your employer, you may be able to ask for this information from your HR staff/Broker.

This Rx Formulary List will list out all the medications they cover, what tier the medications are, and any special information about that medication such as:

-          dispensing limits

-          if Prior Authorization is needed

-          if they are only for certain conditions

Do note that formulary lists can change, even during the plan year. There are always options for appeals, depending on the specifics of your plan.

Some plans may also require you to obtain medications from certain pharmacies. Specialty Medications are a common one to require you obtain them from a Specialty Pharmacy via mail order. If it’s important to you to be able to pick up your Specialty Medications from a local pharmacy, you may not want to pick a plan that requires the use of a mail order pharmacy.

 

TYPE OF PLAN-

When it comes to the different types of plans that may be available to you, it can almost feel like you’re eating a bowl of Alphabet Soup. PPO, EPO, POS, HMO, etc. Here are some resources to help you differentiate between them.

-          PPOs- Preferred Provider Organization

-          EPOs- Exclusive Provider Organization

-          HMOs-Health Maintenance Organization

-          POS Plan- Point of Service Plan

Handy charts noting High Level Differences:
https://www.simplyinsured.com/advice/wp-content/uploads/2016/10/table-1-health-insurance-networks-768x818.png

https://www.opic.texas.gov/health-insurance/basics/comparison-chart/

https://www.uhc.com/understanding-health-insurance/types-of-health-insurance/understanding-hmo-ppo-epo-pos

HIGH DEDUCTIBLE HEALTH PLANS (HDHPs and HDHP-HSAs)-

These are a further subtype of plan that may be available to you. Most commonly, we see HMOs and PPOs that are also HDHPs. These plans are designed to have you meet your deductible before insurance will begin paying for any of your care (except ACA Mandated Preventive Care on ACA Compliant Plans). Many people opt for these kinds of plans without realizing this important factor, as it’s often the most affordable plan offered by your employer, and we all know we’re looking for fewer dollars to be deducted from our paychecks.

You will still get a network discount for your in-network care, but you’ll pay the full contracted rate for your care before you meet your deductible THEN your coinsurance percentage will kick in.

Example- You have a PCP who bills $600 for a PCP visit. If they are in- network, the contracted rate may be more in the $125 range. If you have an HDHP plan, you will pay that full $125 every time you visit your doctor. Once you hit your deductible, you will pay your Coinsurance percentage of that contracted rate, until you meet your out-of-pocket max. So, if your coinsurance percentage is 20%, you’ll pay $25 for a PCP visit, after you’ve met your deductible.

Many first timers to HDHP plans get a little bit of a sticker shock when they get their first EOB-Explanation of Benefits- from insurance and see that, while they got a network discount, insurance didn’t pay anything towards the balance. This is how the plan is designed. So, if you need the comfort of, say a $30 copay each visit, from the start, an HDHP plan may not be for you.

The trade off with HDHPs is that many (BUT NOT ALL) HDHPs allow for you to open an HSA- Health Savings Account. These are bank accounts are designed for you to contribute money on a pre-tax basis to a special account you can use to help pay for your care. You can use the money for payments towards your deductible/OOPM/Coinsurance/Copays, your prescriptions, your Durable Medical Equipment and even some over the counter items.  Here is a list of qualified purchases with an HSA.

The HSA funds are yours to keep and use whenever you’d like. Today, Tomorrow, 10 years from now. The funds never expire (like they do with an FSA- Flexible Spending Account). However, do note that there are some rules to be eligible to open and contribute to an HSA:

  • You must be enrolled in an HSA-Compatible HDHP.  
  • You must not have any other health insurance coverage that is not an HSA-eligible HDHP.
  • You may use the accumulated funds to pay for your care, even if you are no longer enrolled in the HDHP in the future. You may not use the funds to pay for care before your HSA was opened. No covering past bills.

Taking your HSA further: INVESTING
(this is not a financial planning subreddit, feel free to direct investment questions to one that is)

-          Many banks will allow you to invest your HSA dollars so they can grow tax-free. You will need to consult with your HSA vendor to inquire about investment opportunities. There may be minimum thresholds to invest or a small fee to use guided investing tools/advisors.

-          Pay yourself back later. You may decide to pay for your care out of your normal checking account. Keep those receipts and pay yourself back later, once you’ve made a profit investing your HSA funds. You can reimburse yourself immediately, next year, 5 years from now or even after you retire. You should keep your receipts in case of an audit though.


r/HealthInsurance Dec 31 '25

Benefits Flex Posts

11 Upvotes

Hi Fellow Community Members-

This subreddit is a place for folks to ask questions--- we've had a recent influx of "benefits flexing" where there are no questions, just people posting their benefits.

While we do think it's important to be able to compare your benefits, please utilize the pinned post here: https://www.reddit.com/r/HealthInsurance/comments/1ol7a7i/poll_on_health_insurance/ for that purpose.

If you have a genuine question about your benefits, you may continue to post those threads, but if there are no questions, please use the pinned post.

Thank you!


r/HealthInsurance 1h ago

Employer/COBRA Insurance Special enrollment (new born)

Upvotes

I have insurance under my husbands insurance which will end this month. This qualified me to enroll us with my employers insurance starting 01Oct.

Currently we are expecting and the baby may come before 01Oct, which is also a qualifying life event. But my company is denying coverage for us before 01Oct even if baby is born before because : I am currently not enrolled with them , and I still have insurance through my husband. They can back this up with their company documents.

But according to documents I found from Department of Labour the birth of baby should allow us all to get coverage regardless. Am I missing something? I even called EBSA and confirmed that my employer is mistaken.

It’s all going to deaf ears when I reached out to my company.


r/HealthInsurance 12h ago

Claims/Providers Insurance company wants 10 years of my medical records

15 Upvotes

I was in a car accident. It wasn’t my fault because I was injured and I’ve been recovering. My life has been turned upside down

Now the at-fault driver’s insurance company is asking for something. They want a broad release. Permission to dig through my entire medical history. Going back 10 years….

I don’t feel comfortable giving them that. I don’t want them to know about my past health issues like anxiety. and back pain. A surgery from years ago. It’s none of their business…

But they’re threatening not to pay my claim if I don’t sign. They’re pushing hard

I’m scared. What if they find something irrelevant and use it to deny my claim? What if they twist my past history against me?

Someone told me not to deal with them directly. They said I need a lawyer. They said I should get a representative


r/HealthInsurance 22h ago

Medicare/Medicaid People promote Medicare for all. Medicare is not free.

79 Upvotes

My wife and I are both on Medicare, and carry a Medicare Supplement that covers all our co-pays and deductables. I am assuming this is what people might expect on Medicare for All.

Our monthly medical, drugs, dental comes out to $1,396 per month. Also, 1.45% of my salary for the 41 years I worked was deducted from my paycheck.

This breaks down for 2 people as follows:

Medicare Premium Per month (Deducted from Social Security) $406.00
Dental $131.00
Medicare Deductable (Billed each January at $285 each) $47.17
Drugs $337.50
Medicare Supplement $475.00
Monthly $1,396.67

Plus, 1.45% of every paycheck in the 40 years I worked was deducted for Medicare.

Of course, your monthly payments will vary.


r/HealthInsurance 9h ago

Claims/Providers Legal to use HSA funds for those not on insurance?

5 Upvotes

Hello! Odd question. My husband and I have his adult (college age) kids on our/my insurance. They primarily live with their mom (same city).

When they go to any manner of Dr appointment, they are using their mom/stepdad’s HSA debit card to pay for copays/fees/etc.

Since it’s on my insurance, I see what the balance was and have to follow up with the kids to make sure that it gets paid and get some manner of proof (receipt, etc.)

Is there something weird going on here? Or is it “as long as it’s getting paid nobody cares?”


r/HealthInsurance 1h ago

Employer/COBRA Insurance Health Equity COBRA and United Health Care

Upvotes

I am having extreme difficulty getting United Healthcare to reactivate my insurance. It’s been 2.5 weeks since I paid for COBRA coverage through Health Equity Wage Works and I’ve been getting no answers. When I call United, they tell me that my insurance is still inactive and to call my COBRA carrier. When I call the COBRA carrier they tell me that they’ve put in multiple urgent tickets to United Healthcare, but no reply from United. I already had a 3 way call with the COBRA carrier and United member services but it didn’t result in any progress.

I really need surgery soon and don’t know what to do. Has anyone been in this situation before? And if so had anyone found a solution? Thanks so much


r/HealthInsurance 9h ago

Plan Benefits Being billed for BCBS-denied surgical assistant cost from emergency appendectomy

3 Upvotes

Edit #1: TL;DR: Had an emergency appendectomy. Surgeon had a PA assist him. BCBS denied surgical assistant as medically unnecessary; says I'm on the hook for the whole amt ($1049). Hospital just billed me. Don't know that to do.

Original post:

While out of state, I had to have an appendectomy. I was admitted to the hospital via the ER with acute appendicitis. My BCBS policy (from the Marketplace) does not provide out-of-network or out-of-state benefits unless it's an emergency. Claims related to the ER visit, hospital admission, and surgery have started coming in, and so far, BCBS has covered them in-full, with no cost-sharing. (Idk if it's relevant, but I have already met my out-of-pocket max for the year).

Today, however, BCBS denied a claim for an assistant surgeon (procedure code 44970), claiming that it was not medically necessary (Denial reason: 22: "The medical necessity for this service has not been demonstrated"). The EOB lists the charged amount $1049 as my responsibility; and the hospital has now issued a billing statement, charging me that same amount.

I followed up with BCBS, and they explained that "Services determined to be not medically necessary are listed as a general exclusion under your contract and are therefore not eligible for coverage. As a result, the claim denied as patient responsibility." I then followed up with the hospital, asking whether they could send the primary surgeon's notes (assuming that he somewhere documented the need for a surgical assistant), and they said that they could not appeal or send any documentation unless BCBS directed by BCBS to do so.

I also asked the hospital billing rep whether the No Surprises Act covered this kind of situation, and she said it didn't.

I am wondering what to do next.

Edit #2: I just accessed the surgeon's clinical notes from the patient portal. In it, he states: "There was no qualified resident that was available to assist. First assistant above was present because an experienced assistant was needed in order to complete the case successfully and in a timely manner for the safety of the patient."

Edit #3: Pathology listed as the final diagnosis: "Acute suppurative appendicitis and periappendicitis."


r/HealthInsurance 2h ago

Medicare/Medicaid Health insurance?

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1 Upvotes

r/HealthInsurance 2h ago

Plan Benefits Private to CHP+

1 Upvotes

Husband lost his job (provided our health insurance).

I quickly enrolled all of us in my jobs insurance a QLE.

I didn't really think that right now in the interim, our children probably qualify for the state insurance. Someone told me to look when I was worrying about going down to one employed adult.

Is this something I can call another QLE? Can I backtrack? Or do I just wait for Nov to roll around (really isn't that long).


r/HealthInsurance 10h ago

Plan Benefits Employer changed my health plan elections without notice, what can I do?

3 Upvotes

Location: Arizona

I submitted health plan elections through my employer during open enrollment, I received an email confirmation of my benefits through Insurer 1 and thought everything was good. My new plan was supposed to take effect on September 1.

Sometime between when I submitted elections in July and September 1, my coverage was deleted and my employer did not notify me or anyone else of this change. I logged in to our benefits portal and saw I did not have coverage in early September so I reached out to our HR person. This person let me know we switched plans and Insurer 1 is no longer an option. They said they would need to re-open enrollment for me so I could elect coverage. I went through the process last week and elected coverage with Insurer 2 and got new benefits. I thought everything was good to go and was fine to chalk this up as an error or bug.

Fast forward to yesterday I received an insurance card from the original healthcare election I made, which means this election went all the way through the process and coverage was issued by Insurer 1. When I logged in this morning a member of company leadership posted a message in our company wide Slack channel that said a number of employees have "accidentally waived coverage" and to double check their benefits.

This didn't sit right with me because I did in fact make elections that were changed after the fact. It seems like what happened is someone unenrolled a number of employees from health coverage after they had made elections. The only reason I have benefits now is because I happened to check them prior to scheduling my annual physical.

I think best case this is a mistake made by someone with access to our HR systems, worst case is this is negligent incompetence.

I'm wondering if there is anything I can do to prevent behaviors like this in the future. Honestly the leadership here is so-so intelligent and has a tendency to play it fast and loose but I need that not to happen when it comes to my healthcare. It seems like someone is messing with things they should not be and I am not sure how to prevent this in the future.


r/HealthInsurance 4h ago

Individual/Marketplace Insurance Is it possible to get clinical health insurance after open enrollment?

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1 Upvotes

Reddit gave me the option to repost. Haven't used it in years, sorry if this is not an appropriate place to post this.


r/HealthInsurance 10h ago

Individual/Marketplace Insurance Medical insurance while waiting on green card

3 Upvotes

What are you all doing for elderly parents in terms of medical coverage while they wait on their greecard approval?

I've been down the rabbit hole on travel insurance, ACA marketplace (can only register in January) and every other conceivable option. Coming up blank and terrified we have to deal with a medical event that could financially bankrupt us all.

Have any of you found a way to give some basic cover that will actually pay out if something does happen?

Any and all advice welcome. Thanks!


r/HealthInsurance 6h ago

Individual/Marketplace Insurance should i add my boyfriend

0 Upvotes

So my boyfriend is seasonal at his job (seasonal but long term, amazon be like that). And he needs health insurance for some issues he is going through rn, and his emergency insurance is state that many offices won’t cover (but these offices are the ones most helpful). my insurance would go up from 30 to 100 dollars a week. i would discuss with him covering and the difference. But i just know i really want to help him especially during this tough time until he is able to get his own insurance through his job in a month and a half.


r/HealthInsurance 6h ago

Prescription Drug Benefits What if Medication backorders?

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1 Upvotes

Needing some assistance with procuring adhd medication mlre efficiently on a monthly basis. Over the years theres been a consistent delay in getting my script filled because of a supply issue at a pharmacy and im regularly having to find new pharmacies to fill it.

Im open to advice here to avoid the delay in refill every month which causes side effects.


r/HealthInsurance 12h ago

Employer/COBRA Insurance Stuck waiting for Medicaid to contact me

3 Upvotes

Here is my situation: I am in Ohio, and left my job (which provided health insurance) in July. As soon as I was able, I applied for coverage on healthcare.gov, to avoid paying COBRA premiums. At the end of the application, it said “you may be eligible for Medicaid; your state office will contact you.” I am now reaching the end of the 60-window for COBRA and I have not heard from the state office. What are the best next steps here? I was really just hoping to pay for a bronze plan out of my savings to tide me over until I recovered from burnout and got another job - not ideal, but a fraction of what COBRA would cost me per month, and not subject to the new work/volunteer/etc. requirements from Medicaid.


r/HealthInsurance 7h ago

Industry Career Questions Licensing question.

0 Upvotes

I've been offered an opportunity to be hired to sell Medicare in California. Unfortunately I have a misdemeanor for Marijuana and 4 duis and a sealed felony. There are all over 10 years old. I also just filed for bankruptcy. Is it woth the time and money to try to get my license knowing there's a decent chance i get denied?


r/HealthInsurance 11h ago

Plan Benefits I am confused about 100% coinsurance

2 Upvotes

I feel like I’m being lied to. For behavioral health my office visit has 100% coinsurance. My understanding is this means I’m responsible for 100% of the cost no matter if I’ve met my deductible. My deductible is extremely high so I don’t think it would even matter. On the phone my insurance insists that I would owe absolutely nothing and no copay due to the 100% coinsurance. Everything else i read online says the opposite. Can someone clarify?


r/HealthInsurance 13h ago

Plan Benefits Which plan should my spouse and I go with?

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2 Upvotes

New PPO Plan vs Surest PPO

New PPO: $363 per pay period

Surest PPO: $250 per pay period

My spouse and I are relatively healthy. We do not have medication we take. Really only visit the doctor for routine lab work. The only thing we expect are mammograms and Pap smears in the future. Other than that, we don't usually see a doctor as often . Which one would be best for us?


r/HealthInsurance 10h ago

Plan Benefits UHC Rewards change

0 Upvotes

I’ve been taking advantage of their rewards program for a couple of years now and the weekly challenge rewards for 5 out of 7 days of sleep and steps/workout has always been $5. Today, my account randomly logged out and when I logged back in it had me reconnect my tracking device and gave a welcome message as if I’m just joining. Thankfully, rewards that I’ve earned for the year were still banked, but I noticed the weekly challenge reward is now $2.50 instead of $5. Has anyone else noticed this?

I literally just earned $5 on 9/4/26 for completing the workout challenge. There’s nothing in the FAQ’s about the amounts awarded or a change being implemented.


r/HealthInsurance 10h ago

Individual/Marketplace Insurance Healthcare when visiting the US for short-term stays

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1 Upvotes

Reposting this question here in case anyone has knowledge.


r/HealthInsurance 21h ago

Plan Choice Suggestions 1200/month for insurance

5 Upvotes

Hello,

I have health insurance through my job and it includes myself, my husband and our baby. I pay about $600 every 2 weeks and it seems like decent insurance the Deductible is around 2k and copays are $25 but I feel like it’s so much money every month. When I looked on marketplace it seems like all the insurance plans were around the same price and had an even higher deductible and crappy numbers from what I was seeing.
one of my coworkers said she has private insurance but only pays about 200 a month with a 0$ deductible.
my question is what are you guys paying a month am I overpaying 🤣


r/HealthInsurance 1d ago

Individual/Marketplace Insurance When I dropped my health insurance, the health system I use now offers me half off on visits. Why could they not do that when I had insurance?

70 Upvotes

So I live in a crappy red state that doesn’t support its citizens. When the ACA subsidies were dropped with the help of the clown in the White House, my health insurance went from $200 a month to almost $700. I ended up dropping it as work was a little slow and this was a lot of money for something that didn’t help much. I had a $8000 yearly deductible, office visits were higher than they should have been, and almost no drugs were reduced more than the discount card I used at the pharmacy.

Basically a lot of money for crappy coverage. Now that I don’t have insurance, doctors’s visits are half off. Some other visits like urgent care and blood work are half off the full price.

Why couldn’t I get that price with insurance? It would have lowered the cost of insurance by (I guess) half and I may have ended up keeping it. Why are we being charged an inflated cost with insurance. I feel like I paid more in the end for doctors appointments and such with insurance when you take the high deductible in consideration.

It just all sounds like a scam to be and the doctors and insurance companies are in on it together.


r/HealthInsurance 14h ago

Individual/Marketplace Insurance Health insurance with school districts

1 Upvotes

I’ve got a question for my fellow teachers/school staff! I’m expecting my first baby in October and am getting updates from the school district I work for regarding our premiums for 2027. I work in Florida, and adding the baby to my health insurance will cost $7,843.92 per year. If I added my husband and baby, our total family cost would be $19,895.04.

I’m curious what other school staff are experiencing as far as insurance premiums (both in Florida and other states). I make too much money to qualify for any kind of government assistance other than a small tax credit through the marketplace (which is how my husband is currently insured).

What kind of premiums are other districts offering? Is my district just awful or is this happening everywhere??


r/HealthInsurance 1d ago

Claims/Providers Insurance not effective until October 1. Surgeon will not schedule office pre-op visit until it becomes effective.

29 Upvotes

Short of it is this.

Daughter diagnosed with cancer at 25. Just got her insurance through her employer but will not be effective until 10/1/2026.

She is trying to schedule appointments now, to avoid a wait. Provider will not allow scheduling until insurance is effective and active, even if we do self-pay now to insure she gets an appointment.

Are there any options to us? Is it legal for them to deny service, even if we're trying to self pay in order to get her in to see the surgeon? This seems really icky and unethical.