How to Kick the Tires on a Health Plan: A Simple 5-point Checklist

Deciding which health insurance plan to buy is a bit like bobbing for apples. You can’t stay submerged in the minutia too long or you’ll drown of frustration.

Before you get sick digesting all the fine print, there are some components of a health plan benefit summary that are critical and others not so much. When choosing a plan, you should think about your total health care costs, not just the premium you must pay to your insurance company every month.

Assuming you don’t have all day to compare Plan A to Plan B, start by zeroing in on the following components. You can always dig deeper as needed.  Here are the top five health plan benefits to compare before making your final insurance decision:


The amount you pay for covered health care services before your insurance plan starts to pay. With a $4,000 deductible, for example, you pay the first $4,000 of covered services yourself.


The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.

Let’s say your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%.

  • If you’ve met your deductible, you pay 20% of $100, or $20. The insurance company pays the rest.
  • If you haven’t met your deductible: You pay the full allowed amount, $100.

Out-of-pocket maximum:

This is the most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.

Of course the lower your out-of-pocket maximum the better, though it also means your monthly premium will likely be higher. For 2021 Marketplace plans, the out-of-pocket limit can’t be more than $8,550 for an individual and $17,100 for a family.


Health insurance networks come in a number of flavors. The first and most important question to answer is whether your primary care physician and specialists are in the plan’s network.

  • EPO (Exclusive Provider Organizations) are the most restrictive and usually only cover services if you use in-network providers. They also require a referral to see a specialist, though there are exceptions.
  • HMO’s (Health Maintenance Organizations) require a referral to go to a specialist and you will pay more if you go to an out-of-network provider.
  • PPO’s (Preferred Provider Organizations) allow the most network freedom. They allow you to use doctors, hospitals and providers outside the network without a referral or additional cost.
  • Direct Access plans which are similar to PPO’s. They allow a full spectrum of services and full access to specialists without the need for prior approval from your primary care doctor.


Health plans will help pay for the cost of certain prescription drugs but which ones and how much they pay depends on the plan. The best thing you can do is to look up the drug you are taking to see where the drug you have been prescribed falls on your plan’s formulary (drug list), and how much or how little the plan will pay. You can look this up by using a link that appears in the detailed Summary of Benefits that every plan has. And while you’re at it, you should also look up whether your physician and specialists are also in or out-of-network.

So there you have it … the big five factors you should focus on when comparing health insurance plans. After you’ve narrowed down your choices based on these keys, and of course the premiums of each, you might also look at extras such as the preventative services and any covered.

And if going through this checklist still seems like a burden you don’t want to bear, Insureous agents are standing by to sift through all the dozens of plans that will best meet your needs and budget. Just call 904-295-8498 or fill out the contact us form.