Key Considerations When Purchasing Health Insurance

Acquiring the right health insurance policy demands thoughtful evaluation and analysis to align with your requirements and financial plan. Given the multitude of policy options offered by various insurance providers, interpreting the terminology found within policy agreements can be challenging. A comprehensive understanding of the key elements in health insurance plans can streamline your quest for suitable coverage, making the process more efficient and less stressful.


Types of Policies

Health insurance plans encompass a variety of categories, with the predominant majority structured as managed care arrangements. In managed care models, healthcare services are delivered by designated groups of healthcare providers and facilities at predetermined rates. Some policy categories confine benefit coverage to in-network healthcare providers, while others include provisions for out-of-network services. The nature of your plan also dictates your flexibility to seek medical care and consultations. Specific policy types mandate referrals from primary care physicians before approving specialist visits for coverage. Plans that provide out-of-network coverage and unrestricted access to any physician come with a higher price tag.

The health insurance sector offers four fundamental policy categories, comprising Health Maintenance Organizations (HMOs), Point of Service Plans (POS), Preferred Provider Organizations (PPOs), and Fee-for-Service Plans, often referred to as indemnity plans. Opt for the plan that aligns with your personal and family requirements, financial capacities, and the extent of coverage it offers.


Health Maintenance Organizations (HMOs)

A Health Maintenance Organization (HMO) is a collective insurance plan that mandates insured individuals to obtain healthcare services solely from participating providers, and this can only be done with a referral from their primary care physician (PCP). Services provided by healthcare providers outside the network are not included in coverage. HMO plans entail prepayment for health insurance coverage, with monthly premiums covering a range of healthcare services, including preventive care like gynecological exams, prostate exams, and, in certain instances, dental and vision screenings. For most services, members of HMOs are typically required to make copayments.


Preferred Provider Organizations (PPOs)

The PPO insurance plan revolves around the insurance company’s negotiations with physicians, clinics, various healthcare professionals, and hospitals, securing services for their policyholders at reduced rates. Within the framework of a PPO, insured individuals have the flexibility to select either in-network or out-of-network healthcare providers. For services rendered by in-network providers, members receive higher reimbursement, while they shoulder a greater portion, if not all, of the expenses associated with out-of-network providers.


Fee for Service Plans

Fee-for-service plans, also known as indemnity plans, were once prevalent, particularly through the 1980s, but have become increasingly scarce. In these plans, the insured pays a monthly premium and typically must meet an annual deductible before any benefits become payable. Following the deductible threshold, the insured usually also bears co-insurance responsibility, which involves a specified percentage of the charges. Under most fee-for-service plans, insured individuals enjoy the freedom to choose their own healthcare providers, and as long as the service is covered under the plan, they become eligible for reimbursement. The cost of indemnity plans typically varies in accordance with the deductible amount and coinsurance.


Point of Service Plans

Point of Service Plans, often referred to as POS plans, represent a blend of Health Maintenance Organizations (HMOs) and fee-for-service plans. With a POS plan, you have the liberty to select a primary care physician who will oversee your healthcare and provide referrals for other services. Opting for this route typically means having no deductible and usually incurring only a minor copayment. Alternatively, you can circumvent your primary care physician and directly consult an out-of-network specialist. In such cases, you will be subject to a deductible and required to pay coinsurance, akin to indemnity plans.



Numerous health insurance plans incorporate deductibles. These are typically substantial one-time sums designed to lower the standard monthly premium for your coverage. Deductibles signify the monetary threshold that you are responsible for covering from your own resources before the insurance company initiates benefit payments. It’s imperative to ensure that your deductible remains within the confines of your emergency fund, safeguarding the stability of your financial standing and preventing the risk of insurmountable medical expenses.


Prescription Benefits

The majority of health insurance plans typically present a selection of prescription drug benefits tailored to your specific requirements. Commonly, three-tiered plans have emerged as a means of reducing the overall policy cost. In these tiers, generic medications are the most economical, followed by popular brand-name drugs at a slightly higher cost, and less common brand-name drugs at the highest cost. Medications in this top tier, referred to as ‘non-formulary’ drugs, can represent a potential substantial expense for both the policyholder and the insurance provider. If you are currently on a regular monthly regimen of non-formulary prescription drugs, it’s crucial to make informed choices regarding your coverage to prevent excessive pharmaceutical expenses at the pharmacy.


Maximum Out-of-Pocket

To mitigate the risk of overwhelming financial burdens, health insurance policies feature protective thresholds known as ‘maximum out-of-pocket’ limits, outlining the maximum amount you can be responsible for in covering your healthcare expenses over a given year. These limits vary between different plans and encompass all deductibles. However, it’s important to note that many plans do not factor standard office co-payments or prescription drug expenses into the maximum out-of-pocket calculations. It’s essential to ensure that your policy’s maximum out-of-pocket limit aligns with your financial capacity.


Network Size

When buying health insurance, examine the carrier’s network to check if your current physicians participate with the program. If they are not listed as in-network providers, you may have to purchase a more flexible plan that covers out-of-network treatment, or consider changing doctors. Additionally, the distribution of physicians in your geographic area should be large enough to include several specialists in every major field. This allows you to choose from several specialist providers and seek multiple opinions on an issue before deciding on a course of treatment.