5 Things To Know Before Choosing Your Insurance Policy

Have you ever wondered why health insurance quotes are so vital for everyone? There are millions of individuals that have struggled to pay for their medical expenses while in between jobs. According to the U.S. Census Bureau’s 2025 health coverage report, roughly 25 million Americans remain uninsured at any given point in the year. There have also been many individuals that have health insurance, but they still have co-pays to pay for prescriptions and what is left over after the insurance pays what they are required to cover according to the policy. There are 5 things you should know before you make a final decision on which health insurance you choose.

1) What type of plan are you considering? As you conduct your own research on health insurance quotes, it becomes clear that every insurance company has something to offer. The four most common plan types — HMO (Health Maintenance Organization), PPO (Preferred Provider Organization), EPO (Exclusive Provider Organization), and HDHP (High-Deductible Health Plan) — each carry different rules about referrals, networks, and costs, as explained by HealthCare.gov’s plan type guide. Make sure that you compare the plans you are researching before you make your financial decision. Understand the role the policy will play for you as it pertains to the needs of you and your family. Insurance is an important financial decision, and you should make sure that you are covered for medical expense, prescriptions, surgical situations, and more. Also consider what else your insurance policy covers as it relates to anything that takes place after surgery. What about therapy? These are important aspects of your health insurance to cover.

2) What does your policy cover or not cover? Although many health insurance companies may offer coverage for physical therapy, there are some that may only cover therapy while in the hospital, known as “inpatient therapy”. You may discover that your employer does not provide pharmacy coverage. Most plans do offer prescription coverage, but there are some examples in which certain medications may not be covered. The Centers for Medicare and Medicaid Services (CMS) notes that every insurer maintains its own formulary — a list of covered drugs — meaning the same medication may be covered under one plan and excluded from another. There are some policies that choose not to cover inhalers for asthma. They may charge anywhere from $50–$70 per inhaler because it’s not something that every single individual on earth may need. Therefore, it’s important to look for a plan that covers inhalers if that is important for you. The American Lung Association estimates that more than 27 million Americans currently live with asthma, making inhaler coverage a meaningful consideration for a significant portion of the population.

Premium and deductible figures sourced from the Kaiser Family Foundation 2025 Employer Health Benefits Survey and HealthCare.gov. Individual market figures may differ.

3) How Much Does Your Plan Cost? Cost is an important aspect of your plan so that you can get health coverage while having an understanding of what you can afford. The plan has to make sense for you and your personal needs, but it also has to make sense from the aspect of what it costs. Beyond the monthly premium, you should account for your deductible, copayments, coinsurance, and your plan’s out-of-pocket maximum — all of which are defined by the HealthCare.gov glossary of health coverage terms. You should be able to afford the health insurance you purchase whether it is offered through your employer or not. The IRS Publication 969 also outlines how pairing a High-Deductible Health Plan (HDHP) with a Health Savings Account (HSA) can reduce your taxable income while helping you set aside pre-tax dollars for qualified medical expenses. Go through the entire checklist of the coverage it offers, and if it offers you the coverage you need plus it makes sense within your budget, you can feel confident in your decision to move forward with the policy you choose.

4) Can You Keep the Same Doctors? Once you have been seeing the same doctor for a specific condition it’s important that you are able to keep your doctor. Always research the plans to ensure that the doctors you currently see are a part of your plan. The CMS network adequacy standards require that insurers maintain a sufficient number of in-network providers, but these standards do not guarantee that your specific physician is included. When you change jobs and you get a new insurance card, you’ll discover that it’s a good idea to call the doctor’s office and ask them directly if they are covered under your plan. There are often practices with several doctors working together, but they may all not be on the insurance that you chose. The federal No Surprises Act, enforced by CMS, now protects patients from certain unexpected out-of-network charges, but it does not eliminate the cost difference between seeing in-network versus out-of-network providers. Always double check with your doctor’s office first to ask if they do in fact accept your new insurance coverage.

5) What is availing care, and how much will it cost you? There are several different aspects of healthcare policies, including those that are availing care. This means that it’s a type of healthcare that someone needs or will benefit from. There are so many reasons to cover availing care, meaning that it could be helpful or useful. Anything that a doctor may deem useful or beneficial for a patient to use will be recommended during an appointment. Once a test or type of therapy is ordered it is then sent to the insurance company to determine whether or not they deem it necessary — a process known as prior authorization. According to the American Medical Association’s 2025 Prior Authorization Survey, 93% of physicians report that prior authorization requirements delay necessary care for their patients. Sometimes, these issues may go before a board to be reviewed to ensure that they are medically necessary. The U.S. Department of Health and Human Services (HHS) provides a formal appeals process that consumers can use if their insurer denies a claim for medically necessary care.

Getting health insurance quotes is important so that you know what to expect as you go into the future. You should have a clear path ahead knowing what type of coverage you have, what it includes, and how much it will cost you. Tools such as the HealthCare.gov plan comparison tool and resources from the National Association of Insurance Commissioners (NAIC) can help you evaluate your options side by side. As you research your new plan, you should know what it won’t cover so that you can set money aside for other medical expenses just in case you need them. It’s important that you are always prepared for what lies ahead so that you can feel better about your next step when it comes to getting your health insurance quotes. Ask questions, take notes, and always ask those you trust for advice as you move forward with finding the best policy for yourself.

Conducting your own online research is one of the best ways that you can be sure to get more information regarding how insurance works and how you can work it to your advantage. Reputable starting points include the NAIC Consumer Information portal, the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA), and your state’s department of insurance. There are many things that you’ll need to know before you make your final decision.

Frequently Asked Questions

What is the difference between an HMO and a PPO health insurance plan?

An HMO (Health Maintenance Organization) requires you to use a specific network of doctors and get a referral from a primary care physician before seeing a specialist. A PPO (Preferred Provider Organization) lets you see any doctor without a referral, including out-of-network providers, but charges higher premiums for that flexibility. According to HealthCare.gov, neither plan type is universally better — the right choice depends on how frequently you use care and whether your current doctors are in-network.

How much does health insurance cost per month in 2026?

The average monthly premium for an individual employer-sponsored plan is approximately $621, while family coverage averages $2,131 per month, based on the Kaiser Family Foundation 2025 Employer Health Benefits Survey. Marketplace plans purchased through HealthCare.gov may cost more or less depending on your income, location, and the level of coverage you select (Bronze, Silver, Gold, or Platinum).

What does “out-of-pocket maximum” mean on a health insurance plan?

The out-of-pocket maximum is the most you will have to pay for covered services in a plan year before your insurance covers 100% of remaining costs. For 2026, the IRS set the out-of-pocket maximum limit at $9,450 for individuals and $18,900 for families on plans that qualify under the Affordable Care Act, as noted by the Centers for Medicare and Medicaid Services (CMS). Once you hit that limit, your insurer pays all covered costs for the rest of the year.

Can my health insurance deny coverage for a medication my doctor prescribed?

Yes. Every insurer maintains a formulary — a list of covered prescription drugs — and medications not on that list may be denied or require a higher cost-sharing payment. Your doctor can submit a prior authorization request or a formulary exception to ask the insurer to reconsider. The Centers for Medicare and Medicaid Services (CMS) explains that all plans must cover certain essential drug categories, but the specific drugs within those categories vary by insurer.

What is prior authorization and how does it affect my care?

Prior authorization is a requirement that your doctor obtain approval from your insurance company before providing certain treatments, tests, or medications. Insurers use this process to confirm that the service is medically necessary according to their guidelines. According to the American Medical Association’s 2025 Prior Authorization Survey, 93% of physicians report that prior authorization delays necessary care, and 24% say it has led to a serious adverse event for a patient.

What is a Health Savings Account (HSA) and who is eligible?

A Health Savings Account (HSA) is a tax-advantaged savings account that lets you set aside pre-tax money for qualified medical expenses. You are eligible only if you are enrolled in a High-Deductible Health Plan (HDHP). For 2026, the IRS contribution limit is $4,300 for individuals and $8,550 for families, per IRS Publication 969. Unused funds roll over year to year, making an HSA a useful long-term savings tool for healthcare costs.

What is the No Surprises Act and how does it protect me?

The No Surprises Act is a federal law enforced by the Centers for Medicare and Medicaid Services (CMS) that protects patients from unexpected medical bills when they receive care from out-of-network providers in emergency situations or at in-network facilities. Effective as of 2022 and expanded through subsequent guidance, the law caps your cost-sharing at the in-network rate in those scenarios. It does not, however, eliminate all out-of-network charges — planned visits to out-of-network providers are generally still subject to higher costs.

How do I appeal a denied health insurance claim?

If your insurer denies a claim, you have the right to file an internal appeal directly with the insurance company. If the internal appeal is denied, you can request an external review by an independent organization. The U.S. Department of Health and Human Services (HHS) outlines this two-step appeals process under the Affordable Care Act. You typically have 180 days from receiving a denial to file your internal appeal, so acting quickly is important.

How do I know if my doctor is in-network?

The most reliable way to confirm in-network status is to call your insurer’s member services line or check the provider directory on their website, then verify directly with the doctor’s office. Provider directories are not always up to date. The National Association of Insurance Commissioners (NAIC) recommends confirming network status before every appointment, especially after a plan change, because provider contracts can change mid-year.

What is the difference between a deductible and a copay?

A deductible is the amount you pay out of pocket for covered services before your insurance begins sharing costs. A copay is a fixed dollar amount you pay for a specific service — such as $30 for a primary care visit — and it is often due at the time of service regardless of whether you have met your deductible. The HealthCare.gov glossary explains both terms in detail and notes that some services, like preventive care, may be covered before you meet your deductible under ACA-compliant plans.