“The first time I enrolled in health insurance, I was so intimidated and confused by all of the options. I wasn’t sure what the words meant; I didn’t know what I was looking for.” If you’re in this place and don’t know if you’re picking the best plan for you, let’s change that right now.

Using CHIP to Pick a Plan

Step 1: Cost

The reason this is the first step is that you cannot understand your plan without understanding some of the basic financial terminology. This will help you analyze what may seem affordable in face-value, but expensive in the long run. 

Copay: the fixed amount you pay for specified medical services, such as doctor visits, imaging, and prescriptions. You will be paying this every time you receive the service.

Deductible: the amount of money you have to pay for medical services before your insurance starts to cover costs. This means until you reach the deductible, your services will be full price. If your deductible happens to be less than the full price of the service, you will be asked to pay the full deductible and copay during your first service.

Premium: the amount of money you pay to your insurance company monthly, regardless if you use any medical services or not. It’s like your membership fee.

My Tip: Typically you want a low deductible and a low copay. This allows your insurance coverage to start with a lesser pay and then you’d be paying a low price with each service throughout the year as well. However, if you don’t think you’ll be needing many medical services in the upcoming year, you may prefer a higher deductible with a low premium (usually an offered plan) so that you’re only worrying about the low monthly payment.

Coinsurance: this is essentially the same as a copay, except it’s a percentage rather than a fixed price. So, the more expensive the service, the more you’d be paying. 

My Tip: Coinsurances can be unexpected in how much you pay. So, I try to avoid coinsurances for primary care providers, specialists, drugs, imaging, and bloodwork. Of course, it may not be possible for all of the categories, but I prefer the services I use most frequently to have a fixed copay and preventive expensive services (emergency room, urgent care, etc.) to be a coinsurance.

Out-of-Pocket Maximum/Limit: out-of-pocket is the total amount of money you have paid for medical services through your copay, deductible, and coinsurance. Every insurance company has a maximum/limit of how much you are required to pay. Once you reach this indicated limit, your insurance pays 100% of covered services for the rest of the year, including deductibles, coinsurance, and copayments. You still have to pay your monthly premium payments however. 

You ideally want a low out-of-pocket max to give yourself the opportunity to reach the limit.

Future tip: health facilities are not usually aware if you have reached your limit. If you are asked to pay a copay when you know you have reached your max, let the facility know and they will not charge you. 

For any additional definitions you come across, check out the growing list of defined terms here.

Step 2: Health Interests

Although not the first step, this may be the most important: figure out what your health interests are. You do not want to be paying for an expensive plan that doesn’t give you what you need, and you do not want the cheapest plan that makes it impossible for you to be covered for anything. 

So in the upcoming year, what are your necessities medically? Here are some examples:

• Are you looking to get a routine check-up with blood tests and urgent care/emergency room coverage just in case?

• Do you think you’ll need imaging done or prescription drugs frequently? 

• Is mental health or virtual appointments (aka Telehealth) important to you?

• Are you athletic and may need physical therapy, X-rays, and orthopedic appointments in case of an injury? 

• Do you have existing medical needs that need regular check-ups from a few specialists? (specialists are doctors for specific conditions that aren’t your chosen primary care doctor, such as endocrinologists, OBGYNs, orthopedic, internal medicine, etc.)

Just like these examples, figure out what you’re looking for medically based on your health and preference. These preferences will be what you look for in the benefits section of each plan you’re offered. 

Summary of Benefits

Each plan is going to have an included Summary of Benefits (SoB). It should be included as a hyperlink to a pdf and/or a brief version may be seen with the plan description. Below is a short video of what it could look like:

Whether you decide to look at the pdf or the information on the website itself (if available), it is your preference. The pdf typically offers more details however and is more commonly available, so I will be using that as the example.

The Summary of Benefits is going to explain how much you pay and what restrictions exist for those medical necessities you decided earlier. To avoid a wordy confusing explanation, I’ve labeled the important things to watch for in the SoB when choosing your plan in the images below.

Scroll through the pages using the red arrows to understand the layout of the pdf as well as the language. In-network and out-of-network is explained in the next section to better explain its purpose. I also included a quick navigation list of the specific services each page goes over in the example underneath the slider as well (may not be the exact same order for your SoB):

Page Navigation

• Page 1: Deductible, services covered before deductible, bloodwork facility covered by insurance (sometimes indicated, shown in example), out-of-pocket limit, if referral is needed.

• Page 2: PCP vs. specialist payment, blood work payment, imaging payment, generic drug vs. brand drug payment.

• Page 3: Outpatient (includes definition), emergency room bill payment, urgent care payment.

• Page 4: Inpatient (includes definition), pregnancy payment, rehabilitation payment.

• Page 5: Child vision and dental (not covered for adults), excluded services/other services covered but not listed.

Step 3: Providers

You’re almost there! The last step is to make sure the doctor you want to see is accepted by your chosen insurance plan.

If you have a doctor currently you’d like to keep…

If you have any doctors or practices that you currently see, you’re going to want to make sure that your insurance is accepted. To do this, call the practice of your provider, and ask if they accept [insert insurance plan]. Make sure to say the exact plan including the tier (ie. gold, silver, bronze, 1, 2, 3) because sometimes it can make a difference. 

If they accept your insurance, they are considered to be in-network with your insurance. This just means that your insurance will be able to provide coverage, and you will only be responsible for your copay/coinsurance/deductible.

If they do not take your insurance, this means they are out-of-network. Typically, low cost insurance plans will not offer coverage for out-of-network providers, which means you would be paying in full for the service. Some high deductible and/or high premium plans can offer out-of-network coverage.

Whether or not your insurance is accepted is decided by the practice’s discretion and policies. Providers outside of the state that you have coverage in will be considered out-of-network and you will have to pay the facility’s given price for the service.

If you think you will need out-of-state coverage often, you may want to consider a more expensive plan that offers out-of-network benefits. But keep in mind what was mentioned before about a high deductible plan, and aim for as low of an out-of-pocket plan as you can. 

If you don’t have a preferred doctor yet… 

If you don’t have any doctors yet, I would recommend finding a doctor or two you would like to see to make sure your insurance is accepted. Remember step 2 was to understand your health interests. 

If you’re just looking for routine check-ups and bloodwork, find a couple of providers that you’d be interested in having as your primary care doctor (PCP). This is a physician you assign to your insurance as your go-to provider (as long as they state they’re eligible to be a PCP). They may have lower assigned copays and would be the person you go to first for any issues or if you need a referral to see a specialist.

If you know you may need a specialist (ie. OBGYN, urologist, orthopedic, endocrinologist), find a couple doctors or a practice you’d consider going to. Same thing with a physical therapy or imaging facility. 

Call these providers and/or facilities to check if they take the insurance plan you’re looking into purchasing and if they accept new patients.

This ensures that when you do go to see your PCP or a specialist in the future, you already know who you’d like to go to and that you’ve been told they accept your insurance. It’s not fun when you find a doctor you’d like to be seen by but realize mid-year they don’t take your insurance, and you have to change your doctor instead. 

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How to Find the Right Doctor for You?

Are you relying on just one website like ZocDoc or Healthgrades, or choosing a doctor at random? You should learn how to find the right doctor for you here!