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Five Questions to Ask When Shopping for Health Insurance

July 15, 2014
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By Sharon Hollander 

Learn more about Sharon on NerdWallet’s Ask an Advisor

With all of the health care jargon and the many options out there, it’s no wonder that buying health insurance is so confusing. As a shopping expert, here are my ideas about the best way to shop for health insurance — which is no different from shopping for shoes or a car. In fact, if you know what to ask, it might be much easier. Here’s the list of the top five questions to think about when buying health insurance:

5. What are my maximum out-of-pocket expenses? Most health plans now have set annual maximums, which range from about $5,000-$6,350, under the new federal health law. The days of receiving huge medical bills will soon be over.

4. Will my prescriptions be covered? All health plans have a formulary available to review online. If you are among the 70% of the U.S. population currently taking daily medications, according to a CBS News report, it is essential to know if your insurance will pay for it. Visit websites, pharmacies or call your health plan to find out what’s covered. One caveat: If you are prescribed a new medication that isn’t covered, you may need to talk to your doctor about another medication or a generic version of the one prescribed.

3. How much will I have to pay every time I use my insurance? All insurance plans come with a built-in formula that determines the patient’s costs each time they seek care from a provider. You will have an amount due, called a copay, for a hospital admission, emergency room visit, a visit to your doctor and any lab or X-ray costs. The copays will vary depending on your plan and benefits.

2. How much is my annual deductible? This is the amount you have to pay — usually in the calendar year — before your insurance kicks in. Now, in an effort to control costs, some plans require bigger deductibles, and there may be separate amounts for family members as well. You can think of a deductible like the down payment on a car or a house.

And the No. 1 question (drumroll, please):

1. Is my doctor part of the network? If you have a doctor that you trust and want to continue receiving care from, then this is the most important question. Insurance purchased through the marketplace or exchange usually has smaller networks of providers. Many of the new policies can have zero out-of-network benefits. So if you receive care from a provider who isn’t in your network, or who doesn’t take your insurance, you will have to pay for that care out of your pocket.

Forget about the jargon — the EOB, COIN, PPO, EPO Tiers — and focus on shopping smart! If you know what you need, it will be easier to find it. Some people prefer to shop online, while others like to shop in person — and you could contact an insurance broker who will be your personal shopper.