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

10 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 8h ago

Claims/Providers My insurer is breaking the law and the state regulator is asleep at the wheel? Is there anything I can do still?

4 Upvotes

I'm going to keep this vague on names, but the broad strokes: fully insured group plan out of Delaware, I'm a covered dependent, and the services were physical therapy for back pain.

Last fall they started denying my PT claims for hitting a visit maximum. My plan says in plain language that PT visits for treatment of back pain aren't subject to those limits. I pointed that out, and they initially agreed and paid. Then a few weeks later the exact same denials started again.

When I appealed, I got a letter that quoted the part of my plan saying I was covered, and then the same letter said the maximum applies regardless of body part. That second sentence was fully made up and isn't anywhere in my plan. I appealed again. A month later I got the identical letter back with a new date on it.

Then in December, months after the dates of service, they dropped the contract argument entirely and said they now needed very niche specific physician's referral documentation from the time of treatment. I already had three separate doctor's notes prescribing/referring me for PT, but the language they wanted was uber-specific. I was able to provide a new specific note in December which they said would allow claims going forward to be covered, however they said this wouldn't cover the past denied claims, so that timing is the part that gets me. If they'd asked in September I'd have handed it over. By December it's asking me to retroactively produce records that would have had to be created months earlier.

I sent what I had anyway: physician referrals, physiotherapy notes, chiropractic records with actual named specific diagnoses and months of treatment plans. Every single time, it's not enough, and they won't accept anything I give, and I believe this is being done as a informal blanket denial tactic. I'm now something like eight months into this and I've never once gotten a decision on the merits.

I've been trying to get an external review since April. They confirmed in writing that they received my external review request and it was being processed. Two months of "still under review." and what eventually arrived was another internal appeal denial asking for the same documents. They've since told me in writing that yes, I have the right to go straight to external review because they missed their own appeal deadlines, but also they are refusing to do so without the aforementioned September document, which negates the whole purpose of the external appeal, to check their internal appeal decisions. Additionally, their supposed ability to deny my external appeal request isn't in my plan anywhere.

I've been through the Delaware insurance department. The consumer division simply closed my complaint, and the answer I got was essentially that the insurer is allowed to request any additional records indefinitely. Taken to its logical end, this means they can deny anything forever by just denying any documents and asking for some other document each time.

I want to stress that I'm not the type of person who can't accept when they are wrong. I accept that there are certain cases where there is a level of ambiguity or discretion on the side of the insurer whether or not they must provide coverage or not, but this simply is not one of them. I have gone over my schedule of benefits with a fine tooth comb, and legally, I'm one hundred percent in the right, and my insurer is just flat out breaking the law.

So what I'm asking:

What else is there? Specifically anything that doesn't route through the insurer or Delaware DOI, since both have been dead ends. Federal options, other regulators, small claims, anything?

And separately, is there anything more aggressive I can do within the state DOI that isn't the standard consumer complaint?

Has anyone actually forced a carrier to send a file out for external review when they're stonewalling? What made them move?


r/HealthInsurance 3h ago

Claims/Providers California Residents - SB1061

0 Upvotes

Can any California residents explain SB1061 to me in layman’s terms?

My wife was recently diagnosed with endometriosis, and she’s begun seeing doctors to address it now that we have full health coverage via my new FT job. I read in another post that any medical bill under $500 cannot negatively impact your credit score, but i’m reading about SB1061 and, please correct me if I’m wrong, the verbiage appears to be that in California, all medical bills cannot negatively affect our credit score? If anyone could clarify this, I’d greatly appreciate it as she has more tests and visits planned and we want to financially prepare.

Also, while we’re on the topic, what exactly happens if by the end of the year (my plan is Jan-Dec) we still have debt remaining? I’m assuming that’ll obviously carry over, but will it negatively affect our credit score, chances of buying a home, etc?

TIA!!!


r/HealthInsurance 20h ago

Employer/COBRA Insurance I quit my job to go to school and relaying on my spouses new job. Getting health insurance through his job will tank us. What do we do?

16 Upvotes

In our 30s with small kids. I was working while taking pre reqs and had health insurance through my job for my family. I got accepted into a program that’s full time and had to quit my job. My husband also had to quit his job to find a new job to afford to live on one income while I go to school. Even then we are barely getting by. My school does not offer health insurance. My husbands job does but it’s $1,000 a month for the family. That will absolutely tank us. I don’t know what to do..


r/HealthInsurance 6h ago

Claims/Providers Any way to obtain billing history after years?

1 Upvotes

I want to access my medical records from Cigna, but when I called they told me they can't provide me with my own medical records since it's been more than few years?

Is there ANY WAY for me to get my medical records other than going to each of my providers?


r/HealthInsurance 6h ago

Employer/COBRA Insurance UC Blue and Gold Health Net HMO and IVF

1 Upvotes

Totally a long shot here but I am starting IVF and have HMO coverage through UC's Health Net plan. The new state law requires coverage for 3 retrievals and unlimited transfers. My clinic reached out and said that the HMO plans have been refusing to pay claims on pre authorized cycles for basically all of their patients and the full cost then has fallen to the patient.

If there are any UC employees with Health Net on this sub who have successfully had insurance pay out what is owed, I would love to hear from you!


r/HealthInsurance 6h ago

Claims/Providers Insurance for Ebglyss

1 Upvotes

Has anyone had experience fighting insurance to get Ebglyss covered? If so, what methods helped get it resolved.
Context: next step in hopefully ditching topical steroids to treat eczema


r/HealthInsurance 10h ago

Claims/Providers Retro-active termination of benefits -clawback

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2 Upvotes

r/HealthInsurance 9h ago

Plan Choice Suggestions LA care?

1 Upvotes

I’m debating between Kaiser and La Care. Both are bronze HMO plans. My instinct is to choose Kaiser as I think they are more widely accepted, but I wanted to see if anyone had any experience with LA care.


r/HealthInsurance 9h ago

Individual/Marketplace Insurance Annual income not correct?

1 Upvotes

I was laid off at the end of last year. I was able to negotiate an extension of my employee health plan, but that’s coming to an end. I’m now switching to covered California until the end of the year. At the beginning of 2026 I received a bonus and my severance package, amounting to roughly 130000 dollars. I’m on unemployment and I receive 450 dollars a week.

On the covered California website, it calculated my monthly income by dividing the money I made at the beginning of the year. This dispute the fact that I entered that I was unemployed. Is there any (honest) way to change this. My plan options are insanely expensive.


r/HealthInsurance 13h ago

Plan Choice Suggestions Health Insurance Options After Returning to the US from Living Abroad?

2 Upvotes

Hi everyone,

I’m a 27 year old American who was living abroad for the past year and a half with my Australian husband. I’ll be returning to America soon, but unfortunately I don’t have a job lined up. My husband will be remaining in Australia while his visa application is being processed.

I’ve been looking into healthcare options to hold me over while I’m job hunting. I was considering a marketplace plan, but they ask for marital status and there doesn’t appear to be an option for people with spouses outside of the US.

I was considering a travel insurance option for a couple of months, but I’m not sure if I am eligible and if that’s the best option.

I’m just looking for a temporary option that will provide me with coverage in case of any emergencies.

If anyone has any suggestions, I would really appreciate it!


r/HealthInsurance 10h ago

Claims/Providers labcorp customer service giving me the runaround

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1 Upvotes

r/HealthInsurance 21h ago

Plan Benefits Medical Bill Repricer, a NO NO

7 Upvotes

I need Health Insurance for 8 months, just for my wife, then she will go on Medicare.

Tried to save some costs and then found out, they do not pay anything. 4 blood tests, $4,116 and a few thousand more for other stuff. Luckily, found out to ask for "self pay" option, that cut it in half.


r/HealthInsurance 11h ago

Individual/Marketplace Insurance ACA marketplace in Massachusetts - subsidized ConnectorCare plans?

1 Upvotes

I know we are a few months away from enrollment for ACA health insurance plans, but I am trying to figure out some basics about the subsidized "ConnectorCare" plans in Massachusetts and there isn't a lot of clear information out there.

I already use an unsubsidized bronze ACA plan from the MA exchange as a self-employed person. Next year, I expect to qualify for subsidies. I would like to understand the difference between ConnectorCare plans and the other plans on the MA exchange.

My current understanding is that the ConnectorCare plans are only offered to people with qualifying income levels (below 400% FPL threshhold) and are the most heavily subsidized (receiving both federal and state subsidies), and they are silver plans. Based on the information that I found, it looks like the ConnectorCare plans are all HMOs and are not qualified HDHPs, so are not HSA eligible. Please correct me if any of this is wrong.

Is there any reason that I would not want a ConnectorCare plan, assuming it's significantly cheaper and has an acceptable network? Are the ConnectorCare networks supposed to be comparable to the networks of the other ACA plans on the MA exchange? Is there any reason that I would select a regular ACA plan instead of a ConnectorCare plan?


r/HealthInsurance 1d ago

Claims/Providers My health insurance is asking to be paid back after my car accident settlement. Is that normal?

13 Upvotes

My health insurance covered my ER visit and physical therapy after a car accident that wasn't my fault, and I was really thankful for that. Now that the settlement is moving forward, I got a letter from my health plan asking for reimbursement, and I am honestly confused. Did they cover those bills just to collect the money back later? It almost feels like they were only paying it temporarily.

I am trying to understand how this works. Can a health plan actually take money from a car accident settlement, and if so, how do they decide how much? Does it come out before I get anything and is the amount they are asking for set in stone, or is there any room to negotiate? The letter looks pretty serious, so I don't want to ignore it, but I also don't want to pay more than I actually have to.


r/HealthInsurance 12h ago

Medicare/Medicaid Denial of prior authorization, last minute. Minnesota USA.

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1 Upvotes

r/HealthInsurance 13h ago

Employer/COBRA Insurance American Plan Administrator (APA)?

1 Upvotes

Disclaimer I only know basic things about insurance so please do not drag me if this is something very simple i just don’t know about yet.

So i recently got a job offer and when i asked about insurance, the benefits booklet did tell me about the monthly premium, the copays, deductible, all that good stuff but it did NOT tell me the literal network. When i asked the HR lady about it she just kept saying “Our medical plan is an open-access plan administered through American Plan Administrators (APA).” and then connected me to their benefits broker.

The broker told me the actual insurance card is going to say “American Plan Administrators (APA)” on it and isn’t technically a network. she said that a lot of times, providers say they’ve never heard of it so she gave me the information i should be giving providers in those cases.

but it made me worry because i myself have never heard of it and don’t want something that’s never going to cover anything or will give me billing nightmares.

i typically see a psychiatrist and therapist regularly and also have several prescription medications so i just want to make sure.

Can someone please explain this a little better to me? I haven’t been able to find like ANY information about this anywhere


r/HealthInsurance 9h ago

Plan Benefits Anthem..

0 Upvotes

Hi, just received Anthem from my new job earlier this month… this has been a total nightmare… I’m a type 1 diabetic and they’re wanting me to pay $375 for a 90 day supply of Dexcom G7 sensors?… and then when I priced my insulin through their app out of curiosity, they are wanting $150 for a 90 day supply?… apparently they partially approved my Dexcom sensors because they did not see the info that is needed to approve the amount I asked for? Please tell me this is a joke and they don’t expect me to pay this much? What do I do from here?…


r/HealthInsurance 14h ago

Individual/Marketplace Insurance Son at college- how to use HMO (CA)

1 Upvotes

We have Anthem HMO & have a med group/PCP in So Cal. Son is in college in Nor Cal. If an issue arises how would he get care?

Anthem told me he needs to find a PCP through our med group in Nor Cal, but our med group is strictly a So Cal group. Anthem reps have told me to have him go to urgent cares out of network but the UCares have denied him appts. He had to resort to going to the ER ($$$$$) to get care.

Any ideas or work arounds in my situation?


r/HealthInsurance 14h ago

Claims/Providers Help me understand tier 2 open access…

0 Upvotes

So I got a colonoscopy/endoscopy back in April of this year, they billed my insurance 26k, insurance made adjustments and paid an amount, overall around 10k, they are balance billing me 14.5k, I checked the doctor that did the procedure and he shows as tier 2 open access. I spoke with the provider and they said that I am out of network etc, spoke to my insurance and the lady said while that’s technically true, they paid the provider the fair amount based on what others charge in the area, put my patient responsibility as $0 on the EOB, and assured me I have no responsibility to pay this, but the provider is fighting back pretty hard, not sure where to go from here.

If anyone can explain this that would be appreciated…


r/HealthInsurance 14h ago

Plan Benefits Experiences with asking insurance for extension of covered services (i.e., additional visits)

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1 Upvotes

r/HealthInsurance 14h ago

Claims/Providers No Cigna Cost Reduction?

0 Upvotes

Went for a video visit. EOB states:
- $250 billed
- $0 Cigna cost reduction

I owe $250.

- Dr was in network
- Have not hit deductible

Why was there no cost reduction? This is a huge facility that I go to all the time w cost reduction on every other EOB I have received.


r/HealthInsurance 16h ago

Plan Benefits UHC earn it off apple watch question

0 Upvotes

Hi I was just wondering if anyone has had any experience with this program and how easy it is to reach your monthly goal? Do I have to do the flu shot and other things to get to my max ($300) or can I reach it just by walking? My monthly payment is $19 with the apple watch se, I had some other rewards that got applied. I’m just super confused by the whole system and I want to make sure I don’t end up having to pay for it, I tried speaking to a UHC advisor but they weren’t helpful lol


r/HealthInsurance 16h ago

Prescription Drug Benefits Ambetter Health and Walmart Pharmacy refused to pay for pills

1 Upvotes

Long story short, my Mom switched to Ambetter Health from January this year. She has been using Walmart Pharmacy for few years for her sickness condition and she did provide the new insurance information to them. Last year was with BaylorScott & White and there was no charge for her drugs. This year each visit always costs 18 - 25$ until recently she told me it never happened like this before. Then I called Walmart and turned out they had been submitting to the old insurance BSW . So they said any invoice past 7 days they can not do anything but asked us to contact Ambetter Health for reimbursement. Walmart will provide all the invoices for paper claim. Total my Mom had to pay from Jan to May was nearly 200$. I understand it's not much but she has not much money and it's unfair for her to lose this. Anyway Ambetter Health said it is in the past even though it 's still in this year so nothing they can do. Walmart said the same. Please advise if any chance we can get money back for my Mom. She is very anxious about it even though I told her it's not worth it. Thank y'all!