How to Shop for Health Insurance
Health insurance isn’t complicated, it’s just something most people haven’t thought about. I spoke with some Russian tourists once and they had no clue what a “hoagie” was. Shopping for health insurance is easier knowing the vocabulary and a few general concepts. Here's a quick guide:
The Most Important Thing: Provider Network
What if I told you about a health insurance that covers 100% of the costs? Sounds great right? Well how about if absolutely zero doctors, hospitals, and RX makers work with that health insurance company? Not so good anymore. That’s like me saying, “I’ll give you one trillion Matt Bucks!” Sounds great, too bad no one in the world accepts Matt Bucks as payment. Same thing with health insurance! The network of doctors, hospitals, and pharmacies that an insurance plan partners with is crucial. It determines which providers and facilities you can use, and how much you'll pay.
PPO = Preferred Provider Organization – Large network, usually national, with more flexibility. You can see specialists and out-of-network providers without a referral, though you’ll pay a lot more for out-of-network care. This freedom comes at a higher cost, making PPOs typically the most expensive type of plan.
HMO = Health Maintenance Organization – Limits you to a smaller network and requires a referral from a primary care doctor to see a specialist. These plans are usually cheaper but come with more restrictions, and has NO coverage if you need to see out-of-network providers except for emergency care, which is usually covered as in-network.
POS = Point of Service – Similar to an HMO, but allows for some out-of-network coverage, though it’s at a much higher cost.
EPO = Exclusive Provider Organization – Works like a PPO but has no out-of-network coverage, except in emergencies. Some plans may require a PCP and referrals, blurring the line with an HMO.
TIP: The most important thing is to check which hospitals, doctors, and pharmacies are in your plan's network. Even a plan with low premiums can be a poor choice if it doesn’t include the providers you need.
THESE NETWORK TERMS ARE GENERALITIES and insurance companies may use these letters in different ways. For example, they may say, "a PPO with no out of network benefit" instead of calling it an EPO. Or say, "an EPO that requires primary care physicians and referrals" instead of calling it a HMO. However, the concepts are the same however you name the plans.
Deductible: https://www.healthcare.gov/glossary/deductible/
The amount you pay out-of-pocket for healthcare services before your insurance starts paying. Deductibles typically apply to larger services like hospital stays, surgeries, and certain medical tests. Some services (like doctor visits) may not require you to meet the deductible first.
Example: If your deductible is $2,000, you’ll need to pay that amount before your insurance covers most services. After meeting the deductible, you’ll typically pay coinsurance or a copay.
Out of Pocket Maximum: https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit
This is the 2nd most important feature of health insurance in my opinion (#1:Network then #2:Out of Pocket Maximum). This is the highest amount you’ll pay in a year for covered medical services (including deductibles, copays, and coinsurance). Once you hit this limit, the insurance pays 100% of covered services for the rest of the year.
Example: If your out-of-pocket maximum is $5,000, you won’t pay more than $5,000 in a year for medical services, even if you have multiple high-cost procedures.
TIP: Look at the out of pocket maximum for both in-network AND out-of-network care. The "Out of Network - Out of Pocket Maximum" can be very important. If Sloan Kettering Cancer Center or a top drug rehab facility in Florida is considered out of network, will that stop you from sending your loved ones there for care? Usually not. Remember some procedures / experimental treatments will not be covered regardless of in or out of network considerations.
Copayment: https://www.healthcare.gov/glossary/co-payment/
A fixed fee you pay for a service, like a doctor’s visit or prescription. Copays usually apply after the deductible is met, but some plans may have copays for specific services without needing to meet the deductible.
Example: A “$40 copay after deductible” means you pay $40 for visits after meeting your deductible. Some services may have a flat “$50 copay, no deductible” which means that you pay $50 regardless of your deductible amount.
Coinsurance: https://www.healthcare.gov/glossary/co-insurance/
A percentage of the costs of a service you pay after your deductible is met. Unlike copays, coinsurance is a percentage of the actual cost of the service. These prices vary WIDELY between hospitals & geographic areas. (Refer to BITTER PILL link below)
Example: If your coinsurance is 20% for a procedure that costs $1,000, you’d pay $200 (20% of $1,000). The insurance company pays the remaining $800.
Emergency Services: https://www.healthcare.gov/using-marketplace-coverage/getting-emergency-care/
In an emergency, health insurance should cover you at in-network rates, no matter which hospital you go to. This includes situations like accidents, heart attacks, or severe illnesses. However, it's essential to review your policy to see how the insurance defines an "emergency."
Example: If you're in an accident while traveling, your insurance should cover emergency care even at an out-of-network hospital, but follow-up care or non-emergency treatment may be out of network.
Understanding Medical Costs
One of the most challenging aspects of healthcare is understanding costs, as prices for medical procedures are often opaque. This article was written in 2013 but it is still relevant: BITTER PILL: Why Medical Bills Are Killing Us. This is the reason I emphasize the importance of the Out-of-Pocket Maximum. If the procedures are covered, you know what your maximum cost is. During a significant medical event for yourself or a loved one, the emotional relief provided in knowing that is the reason you have the insurance.
UPDATE: The NO SURPRISES ACT requires some transparency with medical pricing.
It's difficult to get exact costs upfront since providers typically won’t provide estimates unless you request them through (slow) formal channels. After services are provided, you’ll receive an Explanation of Benefits (EOB), which outlines what your insurer paid and what you owe. To get a rough idea of how much medical procedures cost, you can use tools like Fair Health Consumer , which lets you look up typical costs in your area. If you are customer / employee at a company working with us, contact us through your benefits web page (quickonboarding.com) and we can provide advocacy services to help you.
Finding Good Medical Professionals
Finding a good doctor is subjective. Start by asking for recommendations, reading online reviews, or considering direct primary care models where you pay a monthly fee for unlimited access to a doctor. When selecting a provider, ensure they’re in your insurance plan’s network to avoid unexpected out-of-pocket costs. Remember, hospitals / doctors are business professionals trying to make a profit as well as medical professionals.
Overall, the key to health insurance is understanding how the network works and managing costs. If you know the terms, how networks affect your care, and what services might cost, it’s easier to make an informed decision that fits both your health needs and budget. Here are a few resources that might be helpful:
https://www.healthgrades.com/quality/
https://www.hospitalsafetygrade.org/choosing-the-best-hospital
https://www.zocdoc.com/
https://www.consumerreports.org/doctors/how-to-find-a-good-doctor/
The Most Important Thing: Provider Network
What if I told you about a health insurance that covers 100% of the costs? Sounds great right? Well how about if absolutely zero doctors, hospitals, and RX makers work with that health insurance company? Not so good anymore. That’s like me saying, “I’ll give you one trillion Matt Bucks!” Sounds great, too bad no one in the world accepts Matt Bucks as payment. Same thing with health insurance! The network of doctors, hospitals, and pharmacies that an insurance plan partners with is crucial. It determines which providers and facilities you can use, and how much you'll pay.
TIP: The most important thing is to check which hospitals, doctors, and pharmacies are in your plan's network. Even a plan with low premiums can be a poor choice if it doesn’t include the providers you need.
THESE NETWORK TERMS ARE GENERALITIES and insurance companies may use these letters in different ways. For example, they may say, "a PPO with no out of network benefit" instead of calling it an EPO. Or say, "an EPO that requires primary care physicians and referrals" instead of calling it a HMO. However, the concepts are the same however you name the plans.
Health Insurance Terminology
Deductible: https://www.healthcare.gov/glossary/deductible/
The amount you pay out-of-pocket for healthcare services before your insurance starts paying. Deductibles typically apply to larger services like hospital stays, surgeries, and certain medical tests. Some services (like doctor visits) may not require you to meet the deductible first.
Out of Pocket Maximum: https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit
This is the 2nd most important feature of health insurance in my opinion (#1:Network then #2:Out of Pocket Maximum). This is the highest amount you’ll pay in a year for covered medical services (including deductibles, copays, and coinsurance). Once you hit this limit, the insurance pays 100% of covered services for the rest of the year.
TIP: Look at the out of pocket maximum for both in-network AND out-of-network care. The "Out of Network - Out of Pocket Maximum" can be very important. If Sloan Kettering Cancer Center or a top drug rehab facility in Florida is considered out of network, will that stop you from sending your loved ones there for care? Usually not. Remember some procedures / experimental treatments will not be covered regardless of in or out of network considerations.
Copayment: https://www.healthcare.gov/glossary/co-payment/
A fixed fee you pay for a service, like a doctor’s visit or prescription. Copays usually apply after the deductible is met, but some plans may have copays for specific services without needing to meet the deductible.
Coinsurance: https://www.healthcare.gov/glossary/co-insurance/
A percentage of the costs of a service you pay after your deductible is met. Unlike copays, coinsurance is a percentage of the actual cost of the service. These prices vary WIDELY between hospitals & geographic areas. (Refer to BITTER PILL link below)
Emergency Services: https://www.healthcare.gov/using-marketplace-coverage/getting-emergency-care/
In an emergency, health insurance should cover you at in-network rates, no matter which hospital you go to. This includes situations like accidents, heart attacks, or severe illnesses. However, it's essential to review your policy to see how the insurance defines an "emergency."
Understanding Medical Costs
One of the most challenging aspects of healthcare is understanding costs, as prices for medical procedures are often opaque. This article was written in 2013 but it is still relevant: BITTER PILL: Why Medical Bills Are Killing Us. This is the reason I emphasize the importance of the Out-of-Pocket Maximum. If the procedures are covered, you know what your maximum cost is. During a significant medical event for yourself or a loved one, the emotional relief provided in knowing that is the reason you have the insurance.
UPDATE: The NO SURPRISES ACT requires some transparency with medical pricing.
It's difficult to get exact costs upfront since providers typically won’t provide estimates unless you request them through (slow) formal channels. After services are provided, you’ll receive an Explanation of Benefits (EOB), which outlines what your insurer paid and what you owe. To get a rough idea of how much medical procedures cost, you can use tools like Fair Health Consumer , which lets you look up typical costs in your area. If you are customer / employee at a company working with us, contact us through your benefits web page (quickonboarding.com) and we can provide advocacy services to help you.
Finding Good Medical Professionals
Finding a good doctor is subjective. Start by asking for recommendations, reading online reviews, or considering direct primary care models where you pay a monthly fee for unlimited access to a doctor. When selecting a provider, ensure they’re in your insurance plan’s network to avoid unexpected out-of-pocket costs. Remember, hospitals / doctors are business professionals trying to make a profit as well as medical professionals.
Overall, the key to health insurance is understanding how the network works and managing costs. If you know the terms, how networks affect your care, and what services might cost, it’s easier to make an informed decision that fits both your health needs and budget. Here are a few resources that might be helpful:
https://www.healthgrades.com/quality/
https://www.hospitalsafetygrade.org/choosing-the-best-hospital
https://www.zocdoc.com/
https://www.consumerreports.org/doctors/how-to-find-a-good-doctor/
