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Need Health Insurance? 10 Questions and Answers to Help You Make a Choice

Posted Mar 22nd, 2009 by Trisha Torrey

More and more Americans are finding themselves without health insurance.  For some, getting laid off and the reality of the high cost of COBRA means its time to go in search of alternatives.  Others who may have been uninsured for a long time now realize that healthcare has become a necessity.  That prompts them to look at health insurance options. Still others find themselves getting older, and know that time will catch up to them.  Even if they haven’t needed expensive healthcare in a long time, they know they will soon.

Finding health insurance when you haven’t been insured is not easy.  Finding affordable health insurance is even tougher, although getting sick or hurt and finding oneself with no health insurance is even more expensive. 

You’ll find plenty of listings on the Internet for individual health insurance.  You can probably find a handful or more of local insurance agents who would be happy to help you purchase insurance.  You can also look to groups or clubs you belong to, to see if they offer group insurance which may save you some money.

As you identify possible plans, whether you use the internet or talk to an agent, here are some questions you’ll want answered before you make your decision.  When it comes time to ask questions, it’s good practice to ask two people about each plan you consider.  The agent will give you most of your information, but remember, the agent will be paid only when you sign on the bottom line and write a check.  Insurers are known for the fact that it’s difficult to get a straight answer or consistent answers.  Getting two people to confirm each piece of information is important.

Here are the ten important questions to ask when you’re ready to choose a health insurance plan:

1.       What are your personal circumstances? 
Do you need to insure just yourself?  Or your family?  Do you or anyone you plan to insure already suffer from an illness or a long-term injury?  Where was the last place you had insurance?  Can you document that? 

Why this question is important:  In addition to your ability to afford health insurance, whether or not you can even get insurance will be dependent on your health insurance history.  If you can prove you have been insured over the past year or more, but need to make a change due to other circumstances (like getting laid off), it will be easier to find insurance than it will be if you have not had any health insurance for awhile.  If you already have a pre-existing condition, it will be very difficult to get insurance independently.  See question #4 for more information about pre-existing conditions.

2.       Do the doctors you like accept the insurance plan you are considering? 
Most plans will provide a list of doctors who accept their plans.  You can go online or to their printed material, or you can call the insurer to ask about specific doctors.

Why this question is important:  If you have a good relationship with a doctor, that relationship is valuable.  Choosing the wrong insurance plan may require you to change doctors.  On the other hand, if you don’t have a good working relationship with any providers, then you may decide to save money on a less expensive insurance plan. 

There’s a double-check step here:  Don’t take the insurance plan’s word for whether a doctor accepts their insurance.  Once you have narrowed down your choices to one or two, then call your favorite doctor and ask if they accept those one or two plans.

3.       Does my choice of hospitals accept this insurer’s plans? 
Not every hospital works with every insurer.  Very soon, we patients will have access to new information that will help us learn which hospitals can serve us the best.  That’s because hospitals will be making their medical errors public, including infection rates. 

Why this question is important:  We patients will begin making choices of hospitals based on those errors and infection rates.  You may already have some of that information, and you don’t want to find out that you need hospitalization, and that the cleanest, most error-free hospital does not accept your insurance plan.

4.       If you or your family member has a pre-existing condition, ask whether each insurance plan accept patients with that condition. A pre-existing condition is a chronic illness (like diabetes, heart disease, allergies or asthma) that you have before you ever apply for that insurance. 

Why this question is important:  Some health insurers will not even consider your application if you have a pre-existing condition.  Others may review your history with the condition before they make a decision.  Still others may accept and insure the family members with no pre-existing condition, but will deny the person who has the illness.  This is one question that is variable by the state you live in, and an area that we will see addressed through healthcare reform.

5.       What is the total cost for premiums or enrollments for the year? 
Most insurers will charge you for monthly premiums, or they may charge you quarterly or bi-monthly.  Some may charge an enrollment fee to be put into a group of others like you who want individual insurance.  Still others will tack on a monthly billing fee if you don’t pay for it all at one time.  You’ll find premiums for a single person, for a couple or for a family (three people or more.)

Why this question is important:  You’ll want to compare your annual total for the insurance, not including copayments, to know what your minimum cost will be for the year.  These premiums will be what your insurance costs before you or your family member ever gets sick or ever needs to access the services.  It’s money you will pay even if you are perfectly healthy all year.

Once you have the answers to these first five questions, you will probably have narrowed your choices down to two or three insurance companies and plans. 

Now draw up a set of assumptions that you can use to help you compare each plan to the next, fairly, like apples to apples.  For example, if you have a family of four, you may estimate 12 trips to the doctor over the course of the year, needing a prescription for six of those visits.  Maybe you’ll need 5 medical tests (like blood tests, MRIs, or anything that will require a co-pay.

Apply the next five questions to the remaining choices:

6.       What is the deductible? 
Your deductible is the amount you will pay out of your pocket before insurance will pay for your healthcare. A higher deductible will mean a lower premium, and lower deductible will mean a higher premium per month.

Generally, if you are quite healthy, then you can afford to put your deductible very high and keep your premiums lower, because you won’t need to see your doctor so often.  If you have a chronic health problem (and can even get insurance due to your pre-existing condition anyway) then you are better off keeping your premiums higher and letting your insurance kick in sooner.

A deductible will typically be $250 up to  $5000, and will vary depending on how many family members you are insuring.  That means you will pay that $250 to $5000 before insurance begins to pay for your care.

If you choose a very high deductible, your insurance may be considered to be “catastrophic,” meaning it is intended to take care of you only in a situation that would otherwise be catastrophic to your finances.

7.       What is your visit co-pay? 
This is the amount you pay for each visit, regardless of whether the visit is covered by insurance.  It’s usually something like $25 or $30 per visit.  Along with this question is a similar one:  When does the co-pay apply?  For example, some plans don’t require a co-pay for a well-visit or check-up.  Others will, or won’t charge a co-pay for testing appointments.

Now multiply the co-pay as it relates to your set of assumptions.  A co-pay charged at $25 for each doctor visit and test would be 17 x $25 = $425.  A co-pay charged at $30 for visits but not for tests would be $360.

What is the additional co-pay percentage? (OK, yes, I’m squeezing two questions into one – but they are related!)  Once your deductible has been met, you will still be responsible for additional co-pay amounts, usually expressed as a ratio like 80/20 or 60/40.  That means that the insurance company will pay 80% (or 60%) and you will be responsible for the remaining 20% (or 40%) of the bill.  An 80/20 ratio will require you to pay higher monthly premiums than a 60/40 because it will mean your insurance company is responsible for more of your bill, whether or not they ever really need to pay it.

8.      Does the plan you are considering cover prescriptions, too? 
Not every health plan covers the cost of prescriptions.  If you are very healthy and don’t take prescription drugs often, then this will be less important to you.  But if you do take a prescription on a regular basis, make sure you can get coverage, and make sure the prescription co-pays seem fair.  Co-pays for prescriptions are addressed on a tier basis.  Tier One drugs are least expensive, and the co-pay will be the least amount. Tier Two drugs cost more and Tier Three drugs cost still more.  The co-pays will be expressed similarly, something like $15/$20/$25 or  $25/$40/$50 – for Tiers One, Two and Three respectively.

In our family scenario above, those six prescriptions may cost as little as $90 over the course of the year, or as much as $300 even with coverage, and that’s if they are only needed for one fill.  A drug that is taken daily for a year will be worth 12 of those co-pays because it may have to be refilled 11 times more.  It’s worth it to take the time to do the math.

9.      Is there a cap on the amount the insurance company will pay? 
Missing this question has cost others their entire life savings, so pay close attention.  There are some newer health insurance plans that seem like a great deal because their premiums are so low, and their deductibles are manageable.  What they don’t want you to figure out is that they limit the amount they will pay if you get sick or hurt.

Somewhere in the fine print, you’ll find a statement of annual cap, plus lifetime cap or annual cap.  The lower those caps, the lower your premium.  A health insurance policy that costs you $10,000 over the course of the year in premiums, deductibles and co-pays, but limits your annual reimbursements to $20,000 is no bargain.  You need to look for annual caps of $1 million or more, and lifetime caps of several million. 

If you have trouble telling what those caps are, call the plan’s 800 number and ask.  This is one aspect of a policy that health insurers use to block payments because so many consumers don’t know to ask about them. Some states are considering making caps that are too low illegal.

10.   By now you should have a good idea of which plan will work best for you, but there is one more aspect to consider.  Your plans for the next year may have an influence on your final choice. 

Do you plan to have a baby?  Hoping to have some elective surgery?  Or planning to travel overseas, requiring out-of-the country-coverage?  These questions and any others that might affect, or be affected by, your health insurance may help you make your final decision.

Why this question is important:  Not all insurers offer pregnancy and birth coverage.  Not all insurers expand their coverage area outside the country, although most will cover you while you travel within the United States.  True elective surgery is rarely covered, although which surgeries are considered elective vary from insurer to insurer.

Your life circumstances may influence the choices you make.  Or, your insurance choice may limit your future plans.  You’ll want to take these into account, too, if necessary.


About the author

Trisha Torrey is Every Patient's Advocate. She is a newspaper columnist, radio talk show host, national speaker, and the guide to patient empowerment at

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