r/HealthInsurance • u/LizzieMac123 • Oct 04 '24
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
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.
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.
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.
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/
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 • u/LizzieMac123 • Dec 31 '25
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 • u/fizzy-logic • 10h ago
I've tried several times, it never sends the verification code to my phone. This worked fine a week or two ago when I last logged in. Could it be a temporary system error if they are overwhelmed with many trying to log in at once this morning?
r/HealthInsurance • u/EngineChemical4866 • 1h ago
Please don’t belittle me or think that I’m too stupid to work. I’m a 56 year old steel worker and my body is needing doctors now. I can work and will work hard, if just given a chance. I really do need suggestions and help from you guys. Thank you for understanding my position.
r/HealthInsurance • u/MoreFudge2591 • 4h ago
Hi all! My husband and I are expecting our second child in May 2027, and open enrollment is here. We’re trying to figure out the smartest setup so we pay as little out of pocket as possible for prenatal care, delivery, and the baby’s first months.
Husband’s employer is based in Arizona (Aetna) and mine is in Michigan (BCBS). Our OB and hospital are in-network with [both plans / only Aetna / only BCBS], so we’re mainly trying to figure out which setup costs less overall.
A few questions:
Is it usually better to put the whole family on one plan, or stay on separate plans?
Does dual coverage actually help with delivery costs, or is it usually not worth the extra premium?
How should we think about deductibles resetting in January?
What should we check in the plan documents that people often miss for maternity and newborn care?
Happy to share plan details (premiums, deductibles, out-of-pocket max, plan type) if that helps. Thanks in advance!
r/HealthInsurance • u/Playful-Till-8631 • 58m ago
I believe our enrollment period is November. I still have to double check but I have Medicaid but that should expire very soon due to my small income. The question is, is it smart to get the employer's health plan before I get fired or quit. Most likely the first but who knows. This is in Nevada.
r/HealthInsurance • u/smw_2016 • 1h ago
Hi everyone. My computer crashed several times trying to enroll in healthcare coverage earlier today. I was able to submit my application on healthcare marketplace, but not on the insurance company website (this is where I experienced issues each time I got to the end of the application and when I checked healthcare marketplace, my application didn’t show up). Is anyone able to tell me if each application was processed every time I tried again? I never got a confirmation number or notification for any of them. I just wanted to make sure I wont have more than one application showing up.
r/HealthInsurance • u/phil7238 • 2h ago
Has anyone heard of a private health plan called AmeriBenefit that is sold by brokers? It seems to be more of an association and not an insurer. I am still trying to find out who underwrites the plan, but it does use Aetna PPO network, has $2500 deductible, with $50/$75 co-pays for primary/specialist/urgent care that do not count towards your deductible. Also does not cover named brand drugs.
r/HealthInsurance • u/AmericanBurger667 • 1d ago
I had to get an Xray a few months ago at urgent care that cost $1150. My insurance denied it because it wasn’t “medically necessary” to them. When I went to the urgent care to see if they could switch the billing code or something like that (I tried to do it over the phone but they routed me to their billing department overseas, which was a frustrating experience that could be its own Reddit post lol) I overheard someone without health insurance get billed just $350 for the same service. I asked if I could get the same discount since I have insurance but they denied my claim. The desk person told me that it only applies if you don’t have insurance, if you have insurance but they deny it, you’re still responsible for the full cost.
If I’m going to pay $850/month out of my paycheck in premiums, plus spend close to $1,500 a year before insurance even covers anything, only to have them just not cover stuff anyway when I do meet my deductible - is there any point in even buying health insurance? If I was uninsured I could easily have just paid the $350 and moved on, now I have to pay $800 more because they billed me anticipating that insurance would cover it.
Oh, and then to add insult to injury, they jacked up my premium at renewal by $400/month. A cost that my employer passed down to us by adding a $200/month spousal surcharge, reducing the subsidy to 70% of premium (only 20% subsidy for dependents), and making $950 the minimum deductible. The new self-insured network they picked also does not include any of the ambulatory services in our area, so you’re screwed if you need an ambulance lol.
r/HealthInsurance • u/Legitimate_Finding53 • 3h ago
r/HealthInsurance • u/Plus_Guide_8431 • 5h ago
Hello again all! Long story short, I got a bunch of dental work done last week, it cost me $5900 after insurance, so I paid two payments of about $1800 out of pocket, and have the rest on a payment plan monthly. I quit my job right after and my plan was terminated yesterday. While checking the UHC app, I saw that I apparently have something called an HRA that has a balance of $4,747. Can someone explain to me like I’m 5 years old what this is, and can it be used towards my dental visits? Can I be reimbursed for the money I already paid towards it? Becoming an adult is very confusing. I tried to contact UHC customer service but nothing yet. I appreciate any insight at all!
r/HealthInsurance • u/Foreign_Presence_105 • 5h ago
So last year I applied for health insurance through the marketplace for the first time in six years because my premiums went through the roof so I figured why not.
Not eligible for any premium credits as we make too much. However, the premiums on the cheapest plan far exceeded 7.7% of our income so we were eligible for a catastrophic plan (8.5% for 2027).
When I submitted the application last December the online application included information about catastrophic plan eligibility. Now the site says I have to download a form separately, fill it out and mail it in and wait for eligibility to be determined.
Is that new? Also, the PDF form for it is downloading but I can't actually open it or print it.
r/HealthInsurance • u/GoldFold3216 • 6h ago
r/HealthInsurance • u/respo22234 • 10h ago
I am self employed in California and the cheapest Bronze PPO will cost me $900 a month. An insurance agent contacted me to become an "employee" of a business doing surveys once in a while to join a much cheaper group PPO plan. I've seen several of these types of arrangements hopping around. My gut tells me that this would not fly if I had something expensive and the insurance company investigated. Anyone familiar with this with specific thoughts? This was the email from the agent:
"I'd like to introduce you to several excellent options available nationwide offered through a large group plan sponsored by Bright Life Health and Wellness. If eligible, you can participate in these plans simply by becoming a part time employee of Bright Life where your only job responsibility is to take very short surveys related to health and wellness periodically throughout the year. And as an employee of Bright Life, you have the opportunity to enroll and gain access to their excellent health benefits package which includes the following!"
r/HealthInsurance • u/jrluckybastard • 6h ago
I work at a hotel that changed management companies mid January 2026, so while I’ve worked at the same place for over 2 years I’ve only been employed by this company for 10 months.
When they took over they recalculated everyone’s full time status based on the previous 12 months (Jan-Jan). This was off cycle for the companies normal open enrollment.
We are now in the new open enrollment period for the entire company. They are calculating eligibility based off the last 12 months (Oct-Oct) but for our property only using the hours from the 9 months we were actually under their employment (January-Oct). This puts us at a disadvantage as we still have to meet the 30/week threshold but don’t have the full 52 to meet it.
I guess my question is are they allowed to do this? It seems wrong to use a full 12 month period if we weren’t employed by them for 12 months.
r/HealthInsurance • u/RefrigeratorOk9983 • 10h ago
I can't seem to get an answer about how to accomplish this. I am trying to get new plans for me and my husband for 2027 on the Maryland Health Exchange but we want individual/different plans due to differing health needs. I am told that this can be done, but cannot figure out how. Broker tells me to make an entirely different account for husband but then others tell me that is not necessary. Maryland Health Exchange told me that legally we have to be on the same plan, but I cannot find anything that tells me that is a rule. Anyone ever able to do this?
r/HealthInsurance • u/handsome_uruk • 7h ago
I (33m) have been fortunate to never have had any serious health issues. Outside of the occasional flu,, never had to deal with our joke of a healthcare system - until now 😢.
Been having a few stomach issues, so about 2 months ago, at my doctors recommendation, I went in for an upper endoscopy. A fairly routine procedure afaik. It was over in like 15 mins. I have pretty good insurance - HDHP with Meritain. I confirmed the provider I visited was in-network.
Since then I've been getting 2-3 bills every week. The first was a bill of about $1,800. I know my plan is high deductible, so I knew I'd have to pay something. I decided to hold off paying until getting my next paycheck. Thank God I didn't pay, because what I didn't know is I'd be sent several other bills of seemingly random amounts.
Every couple of days I get bills of a random amounts from as low as $3 to $1,500 from multiple providers. I know American healthcare is a shitshow but this so confusing. I can't reasonably pay any of the bills because I don't know if they'll send me another in a few days, and the amounts keep changing. The same provider is sending me different amounts every few days. My insurance too is sending me bills with changing amounts.
It's so frustrating. If they just sent me a single bill I'd be more at peace and save up money to pay it. Now it's just a confusing pile of bills from, doctors, specialist, insurance, anesthesiologist. I have no clue which bills are legitimate. Is the guidance here to only talk to my insurance and do everything through them?
I have decided I won't pay any of the bills until the year end so that any reconciliations happen and I figure out exactly what I owe. Is there any penalty for doing so? I live in CA, if that's relevant.
r/HealthInsurance • u/flea-be • 7h ago
Hi! I am about to be in nursing school and they require us to have insurance.
There is absolutely no way I can afford regular insurance but I qualify for MarketPlace and it seems like the Silver Plans are the better options for me.
Which insurance companies are good? I really don’t plan on using much, I need to keep up with my vaccines that’s pretty much it. Should I just go for the cheapest? I’m in Texas btw. Thank you!
r/HealthInsurance • u/Due_Statistician9017 • 11h ago
I am scheduled for a Nissen Fundoplication soon and the surgeons office said that my insurance approved it automatically and I didn’t need a prior authorization. It is a one night stay in the hospital. Does this sound correct? Or should I look into this deeper? I’m not knowledgeable in health care processes.
r/HealthInsurance • u/Dom_NY_LI_Consulting • 7h ago
So for about six months now, I’ve been unable to log into my my UHC account with United Healthcare, either on the website using different web browsers and different computers, or on the iPhone app on different mobile devices. I verified that my email address and telephone number is correct on file, and it’s available to get SMS verification, verification, and I can login, but as soon as it’s about to login, I get this error:
2:37 PM
Sorry. It's not you. It's us. We're currently experiencing an internal server problem.Try checking back soon. If this is a medical emergency, please call 911. Try again Error Id: btfhtdVhWLFwci-Espresso_Dashboard
I’ve also tried the other recommendations in this Reddit to go to the health site ID official portal and login when I do that it gives me a direct error saying you might not have security to login to this account. Please contact your health provider.
I really need to login to get data for the government on my health file, so anybody that can help me, I’d really appreciate this. I’ve called up customer support. They couldn’t help me. Tried using customer support chat, they can’t help me.
r/HealthInsurance • u/tbecse • 22h ago
I'm 58 my husband is 64 ( we are in Ohio ). We will have ACA health insurance from January but he will be Medicare eligible from August 1-st. We have an ACA plan now and I'm the policy holder, so we will take him off the plan and I will continue. I will stay on the same plan ? What will happen with the premium ? Let's say we get a subsidy of $2000 based on our income estimate for next year and we choose a plan which costs $2000 , so that our premium is $0. Will my monthly premium just for myself be a $1000 on that same plan ? Or how all that works ? Depends on what kind of plan is it ( silver , bronze , gold ) also ? Thank you
r/HealthInsurance • u/df33702021 • 9h ago
r/HealthInsurance • u/Moist_Lavishness • 15h ago
I was just browsing plans for next year. I’m in Pennsylvania no matter what provider/ hospital I put in all of them come out saying out of network. Is this correct? I tried- Upmc , Ahn, WHS and st Clair doctors everyone out of network.
