Your costs include your premiums and any other out-of-pocket costs your plan requires. Plans with more benefits will cost more. Understand the tradeoffs between the benefits and cost. Compare prices by thinking about how often you will need health care. Then figure out how much that will cost under each plan.

What is the monthly premium?

Can you afford the premium? Lower premiums can mean less benefits and more out-of-pocket costs when you use your insurance. Higher premiums usually mean more benefits and lower out-of-pocket costs.

What are your out-of-pocket costs if you get care?

You will also want to know how much it will cost you when you actually get care. Make sure you could afford your costs if there is an unexpected illness or injury. If you use health care often or could not pay for such an event, then a health plan with lower out-of-pocket costs may be better for you. If you rarely use health care and could pay for such an event, then a health plan with higher out-of-pocket costs may fit your needs instead.

Your out-of-pocket costs will include:

• A copayment, or copay, is the fixed amount you pay for services such as doctor visits and medicine.
• Coinsurance is the percentage of the cost of a service you pay for things like lab tests and x-rays. Your plan will usually have different in- and out-of-network coinsurance levels.
• A deductible is what you must pay every year before your health plan will pay for medical bills or other services covered by your plan. Deductible amounts can range from very low to very high. HMOs won’t have deductibles.

What is the out-of-pocket limit?

The out-of-pocket limit is the most you will pay before the company starts paying for 100% of your costs.

• This limit only applies to your deductible and other out-of-pocket costs during a policy period which is usually a year.
• It does not include your premium, balance-billed charges, or spending on non-essential health benefits or services that are not covered by your plan.
• If you have a plan with a low premium but a lot of out-of-pocket costs, make sure you know the out-of-pocket limit.

People use different health care services based on their medical conditions, age, and family needs. Review benefit info for coverage of medications or services that you use.

Does the plan cover what you or your family need?

All individual health benefit plans sold in Texas must include certain federal and state benefits. But plans vary based on the added benefits they provide. Make sure you know what each plan you consider covers.

• Ask your agent about any special health care needs you may have.
• Review plan documents, like the summary of benefits and coverage, to compare plans and find the plan that meets your needs.
• Find out what preventive services for adults, women, and children are covered by the plan.
• Make sure a plan covers any medicines that you or your family are taking by looking at the plan’s drug formulary list.

Does the plan cover what you might need?

Try to think about the medical care you might need as the result of unexpected illness or injury or any other condition that you might develop.

• Know your family’s medical history.
• Consider your risk of getting a chronic condition that could require a lot of testing or medicine.
• Think about how your age and lifestyle will affect your health care needs and future costs.
• Consider if you will need long-term care. Health insurance covers illnesses or other medical conditions, but will not pay for help with the activities of daily life. You get this kind of coverage with long-term care insurance.

What does the plan not cover?

Some health care services, medical devices, or medicines are excluded from your plan. This is called an “exclusion” and it means that it is not covered and you will have to pay for the entire cost. Common exclusions are long-term care, cosmetic surgery, and dental care. Exclusions will be listed in the summary of coverage. Ask for the plan’s disclosures to find out what they won’t pay for.

How does the plan manage your care?

Health plans may limit your access to specialists or restrict the use of what they consider unnecessary treatments or medicines.

• HMOs require you to choose a primary care physician (PCP) from their network and get a referral before you can use other doctors in the network.
• Some EPOs let you see any doctor in the network without a referral. Other EPOs require a referral.
• PPOs usually don’t require referrals. You can visit any doctor in the network without a referral.
• Find out if there are limits on services or medicine such as limits on how often you get treatment, the number of visits, referrals to specialists, or days of coverage.
• Find out if there are benefit limits per person, family, illness, treatment, or hospital stay.
• Find out if your plan requires “preauthorization” or “prior approval.” This means you have to get permission before you can get a medical service or fill a prescription.

Health plans contract with doctors, hospitals, and other health care providers to create the health plan’s network. If you use network providers, the health plan will pay more of your covered health expenses. You’ll also have lower out-of-pocket costs and your costs will be more predictable. If you use providers that aren’t in your network, you may have to pay for the full cost of your own care.

Is your doctor in the plan’s network?

If you want to get care from a specific doctor or hospital, review the health plan’s directory to make sure the providers you use are in the plan’s network.

• If you already have a trusted doctor or another medical provider in your area, make sure that they accept the insurance you are considering.
• Look at provider directories to find out if the in-network providers are accepting new patients.

Are the providers you need available near you?

Provider networks differ by plan. Some plans only offer narrow networks with fewer provider options, which may make it hard for you to get the care you need. Adequate networks have closer doctors with fewer wait times. Consider wait times for scheduling and the number of providers in your area when evaluating a network.

• General. Use provider directories to learn about each plan’s network.
• Primary Doctors. See if the plan’s service area covers where you live and if the plan has enough doctors and hospitals to provide the care you need.
• Specialists. Think about how far you will need to travel for routine and specialist care. Find out how many options you have for each type of specialist.
• Emergencies. Think about how far you will need to travel to hospitals, ERs, and urgent care centers. Find out if the in-network hospitals in your area have doctors that are also in your network.

Is the plan’s network open or closed?

Plans with open networks will pay your costs even if you use a provider that is not in the network. Plans with closed networks only cover out-of-network costs in specific circumstances.

• HMOs and EPOs have closed networks. You must use in-network doctors, hospitals, and other providers. Except in specific circumstances (such as an emergency) an HMO or EPO will not cover services provided by out-of-network doctors.
• PPOs have open networks. You can use in-network (preferred providers) and out-of-network doctors, hospitals, or other providers. The PPOs don’t pay as much for out-of-network services as in-network services. You will have to pay an out-of-network deductible, a higher coinsurance rate, and any remaining balance charged by the out-of-network doctor.

Can you be balance billed?

If you get health care outside of your plan’s network you can be balance billed. If you get care from an out-of-network provider, you could have to pay for the difference between the amount that your plan pays for the service and the amount the provider charges for the service. If your health plan pays for some out-of-network services, it will still pay less for out-of-network care than in-network care.

• In an HMO or EPO, you usually won’t have to pay any balance billed charges if you received out-of-network care because of an emergency or if there weren’t any in-network providers available to treat you.
• In a PPO, you can be balance billed when you use out-of-network doctors, even for emergency services. Your out-of-network expenses will count toward your in-network deductible and out-of-pocket maximum.
• Check plan documents to find out if the plan has an adequate network in your area or if it has a local market access plan because its network is inadequate.
• If the network is inadequate, find out how the health plan will help you get services, reduce balance billing, and handle out-of-network claims.
• If your balance billed charges from a hospital-based provider are more than $500, you can request mediation.