5 Things You Should Know Before You Choose Your Health 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. 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. According to the U.S. Census Bureau’s 2025 health coverage report, roughly 25 million Americans remained uninsured as of the most recent survey period, underscoring how critical it is to understand your options. 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. Make sure that you compare the plans you are researching before you make your financial decision. The four most common plan types are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), and High-Deductible Health Plans (HDHPs) — each with distinct network rules and cost structures, as explained by HealthCare.gov’s plan type guide. HDHPs, for example, are frequently paired with a Health Savings Account (HSA), which allows you to set aside pre-tax dollars for qualified medical expenses; the IRS set the 2026 HSA contribution limit at $4,300 for individuals and $8,550 for families, according to IRS Publication 969. 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.

Premium figures are national averages for ACA marketplace silver-tier plans as of 2026, sourced from KFF’s 2026 Marketplace Premium Analysis. Individual results will differ based on age, location, and tobacco use.

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. Under the Affordable Care Act (ACA), insurers are required to cover ten categories of essential health benefits — including prescription drugs, mental health services, and preventive care — as defined by the Centers for Medicare and Medicaid Services (CMS). However, specific drug formularies still vary by plan, and certain specialty medications may require prior authorization or step therapy before coverage is approved. There are some policies that choose not to cover inhalers for asthma. They may charge anywhere from $50–$70 because it’s not something that every single individual on earth may not need. Therefore, it’s important to look for a plan that covers inhalers if that is important for you. The U.S. Department of Health and Human Services (HHS) provides a summary of what ACA-compliant plans must cover, which is a useful baseline when comparing policies.

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. When evaluating total cost, look beyond the monthly premium and factor in the deductible (the amount you pay before insurance kicks in), copays, coinsurance, and the annual out-of-pocket maximum. For 2026, ACA-compliant plans cap out-of-pocket costs at $9,200 for individuals and $18,400 for families, according to CMS guidance. You should be able to afford the health insurance you purchase whether it is offered through your employer or not. Tools like the HealthCare.gov Plan Finder and resources published by the Consumer Financial Protection Bureau (CFPB) can help you model your total expected annual cost based on your anticipated healthcare usage. 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’s provider network. 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. Large national insurers such as UnitedHealth Group, Anthem (Elevance Health), Aetna, Cigna, and Humana each maintain different provider networks, and a physician who is in-network under one carrier may be out-of-network under another — a difference that can result in substantially higher costs. The No Surprises Act, enforced by CMS and HHS as of 2022, provides some protection against unexpected out-of-network bills for emergency care, but it does not eliminate the need to verify your doctor’s network status before receiving non-emergency services. There are often practices with several doctors working together, but they may all not be on the insurance that you chose. 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 they deem it necessary — a process formally known as prior authorization or utilization review. The American Medical Association (AMA) has documented growing concerns about prior authorization delays affecting patient care, with their 2025 survey finding that 93% of physicians reported care delays tied to prior authorization requirements. Sometimes, these issues may go before a board to be reviewed to ensure that they are medically necessary. If your insurer denies a claim, you have the right to appeal under federal law, and the U.S. Department of Labor (DOL) outlines the appeals process for employer-sponsored plans.

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. 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. Resources from the National Association of Insurance Commissioners (NAIC) and the Benefits.gov federal portal are good starting points for comparing plan structures and understanding your rights as a policyholder. There are many things that you’ll need to know before you make your final decision.

Frequently Asked Questions

What is the difference between a deductible, a copay, and an out-of-pocket maximum?

A deductible is the fixed amount you pay for covered services before your insurance begins paying. A copay is a flat fee (for example, $30) you pay at the time of a medical visit, regardless of whether you have met your deductible. The out-of-pocket maximum is the most you will have to pay in a plan year; once you reach it, your insurer covers 100% of covered costs. For 2026, ACA plans cap out-of-pocket costs at $9,200 for individuals and $18,400 for families, per CMS.

What are the main types of health insurance plans?

The four most common plan types are HMO, PPO, EPO, and HDHP. HMOs require you to choose a primary care physician and get referrals for specialists but tend to have lower premiums. PPOs give you more flexibility to see out-of-network providers at a higher cost. EPOs are similar to PPOs but do not cover out-of-network care except in emergencies. HDHPs have higher deductibles but lower premiums and are the only plan type compatible with a tax-advantaged Health Savings Account (HSA).

How do I find out if my doctor is in-network?

The most reliable method is to call your doctor’s office directly and ask whether they accept your specific plan from your specific insurer. You should also use the insurer’s online provider directory, but always verify by phone because directories are not always updated in real time. The No Surprises Act (enforced by CMS since 2022) protects you from unexpected out-of-network bills for emergency care, but it does not apply to scheduled non-emergency appointments.

What is prior authorization and when does it apply?

Prior authorization (also called pre-authorization or utilization review) is a requirement that your doctor obtain approval from your insurer before providing certain services, tests, or medications. Insurers use it to confirm that the proposed treatment meets their criteria for medical necessity. According to the American Medical Association’s 2025 survey, 93% of physicians reported patient care delays due to prior authorization requirements. If a prior authorization request is denied, you have the right to appeal.

What is an HSA and how does it work with a health insurance plan?

A Health Savings Account (HSA) is a tax-advantaged savings account you can use to pay for qualified medical expenses. It is only available to people enrolled in a High-Deductible Health Plan (HDHP). Contributions are tax-deductible, growth is tax-free, and withdrawals for qualified medical expenses are also tax-free. For 2026, the IRS allows contributions of up to $4,300 for individuals and $8,550 for families, per IRS Publication 969. Funds roll over year to year and do not expire.

What are essential health benefits and are all plans required to cover them?

Essential health benefits (EHBs) are ten categories of services that ACA-compliant plans must cover. These include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services and devices, laboratory services, preventive and wellness services, and pediatric services. Plans sold through the ACA marketplace and most employer-sponsored plans must cover all ten categories, as defined by CMS. Short-term health plans and some grandfathered plans are exempt and may offer far more limited coverage.

How do I compare health insurance quotes effectively?

Start by listing your expected healthcare needs for the coming year — regular prescriptions, specialist visits, planned procedures, and any chronic conditions. Then compare plans on five dimensions: monthly premium, deductible, copays and coinsurance, out-of-pocket maximum, and network coverage. Tools available through HealthCare.gov and the National Association of Insurance Commissioners (NAIC) can help you run side-by-side comparisons. Do not choose a plan based on premium alone; a lower monthly payment often comes with a much higher deductible.

What happens if my insurance denies a claim?

If your insurer denies a claim, you have the right to appeal the decision. For employer-sponsored plans, the U.S. Department of Labor outlines a formal internal and external appeals process. For marketplace plans, the ACA requires insurers to provide a written explanation of any denial and to offer at least one level of internal appeal and one level of external review. You typically have 180 days from the date of a denial notice to file an internal appeal. If the internal appeal fails, you may request an independent external review.

Can I get health insurance if I lose my job?

Yes. Losing job-based coverage is a qualifying life event that triggers a Special Enrollment Period on the ACA marketplace, giving you 60 days to enroll in a new plan. You may also be eligible for COBRA continuation coverage, which lets you keep your former employer’s plan for up to 18 months, though you pay the full premium yourself. Additionally, depending on your income, you may qualify for Medicaid, which is administered jointly by CMS and individual state agencies with no open enrollment deadline.

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

The No Surprises Act, which took effect January 1, 2022 and is enforced by CMS and HHS, protects patients from unexpected out-of-network bills in certain situations. Specifically, it limits surprise billing for emergency services, non-emergency services at in-network facilities when you had no reasonable choice of provider, and air ambulance services from out-of-network providers. Under the law, you pay only your in-network cost-sharing amount in these situations, and the balance billing dispute is handled between the provider and the insurer.