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Evaluate Plan Options


Evaluate Plan Options

Once you know what plan options are available, you can determine which one is right for your situation. Review your plan materials – such as brochures, benefits summaries and Web sites – to find the details that will help you decide. Things to consider include:

  • Affordability (total cost)
  • Coverage and benefits
  • Access to doctors and hospitals
  • Exclusions and limitations
  • Health and wellness resources

Affordability (total cost)

Consider factors like monthly premiums, copayments, deductibles and out-of-pocket maximums when evaluating your plan options. You should also look into options for saving and paying for health care, such as health savings accounts, health reimbursement accounts and flexible spending accounts.

Monthly premium

Lower monthly premiums can save you money, but they could mean you'll have a higher deductible and higher co-payments or coinsurance. Higher premiums cost more each month, but may provide more coverage to reduce your out-of-pocket costs.

Copayment amounts

Some plans require copayments for every doctor visit. Others cover 100 percent of certain types of care, such as annual check-ups, but require a copayment for other visits, such as treatment for illness or injury.

Annual deductible

This is the set amount you pay for covered health care services before your health insurance contributes to your costs. Higher deductibles generally lower your monthly premiums.

Out-of-pocket maximum

Out of pocket refers to the maximum amount of money you pay out of your own pocket for covered health care services. After you reach that amount, your health plan pays 100% of eligible health care costs.

Health account options

Health accounts are one component of a consumer-directed health plan. They offer another option for paying for, and in some cases saving for, health care costs. The three most common types of health accounts are:

  • Health Savings Account (HSA) – An HSA, which must be paired with a high-deductible health plan, allows you to put away a limited amount of pre-tax dollars from your pay check to pay for eligible current and future medical expenses. An HSA is yours to keep even if you change employers or benefits. And if your employer offers a high-deductible plan, but not an HSA, you can open an account on your own.
  • Health Reimbursement Arrangement (HRA) – An HRA is an account your employer sets up and funds. Like an HSA, it typically is paired with a high-deductible health plan. Your employer decides what medical expenses are covered and whether to let you carry over funds from year to year. But if you change employers, you can't take HRA funds with you.
  • Flexible Spending Account (FSA) – With an FSA offered through your employer, you can put away a limited amount of pre-tax dollars from your pay check to cover eligible medical expenses during the year. Unused funds do not carry over from year-to-year. FSAs can be used with any type of health plan.

Coverage and benefits

Preventive care, such as annual check-ups and routine screenings like mammograms and colonoscopies, can help you stay healthy. Early detection of common conditions may lower your overall medical costs. Check to see which services are provided at what cost by your health plan.

It's also a good idea to try to assess what medical services you and your family might need in the next year. Consider a few questions as you evaluate your options:

  • Do you or your family members see a specialist to manage a chronic condition?
  • Do you anticipate needing major surgery?
  • Do you or your family members take any prescriptions regularly?
  • Do you need additional coverage for vision or dental care?
  • Are you planning a pregnancy?

Access to doctors and hospitals

It's important to understand your plan's requirements when it comes to doctors, hospitals and other health care professionals. For example:

  • Networks. Some plans require you to use doctors and facilities in their network of providers. Others let you go outside of the network for care, but may not cover the costs at the same level.
  • Primary Care Doctor. Some types of plans require you to choose a primary care doctor who is responsible for managing your care and providing referrals for specialists if necessary. If a referral is required, your choices for specialty care physicians may also be limited.

Health and wellness resources

Many plans have tools like personal health records, cost calculators, health screening questionnaires and online coaching programs to help you get and stay healthy. Other things to consider are incentives and discounts on health-related services, such as weight loss resources, gym memberships and smoking cessation programs. Take these into consideration when choosing your plan.

Exclusions and limitations

Read the fine print carefully when reviewing plan options to make sure you're aware of what they might not cover. Common exclusions and limitations include:

  • Substance abuse
  • Mental illness
  • Elective or cosmetic surgery
  • Alternative therapies

In addition, separate insurance is typically required for things like prescriptions, vision care and dental coverage. Your employer may offer these benefits, or you may need to purchase them on your own.