Picking a Health Plan

The story: Two plans, two kinds of year

In a clinic waiting room, Ana compares two health plan sheets on a balance scale while a friend, Marcus, talks about an unexpected ER visit.

1. Narrator: Ana is choosing between two example plans at work. Plan A costs $60 a month. Plan B costs $210 a month.
2. Ana: Plan A is way cheaper. Easy choice.
3. Marcus: That’s what I thought. Then I broke my ankle, and I had to pay the whole huge deductible first.
4. Narrator: In a quiet year, Plan A costs Ana about $870 in all. In a bad year with surgery, it costs $7,720. Plan B’s worst year is $6,520.
5. Ana: So the cheaper plan depends on the year I have. And my doctor has to be in the network.
6. Narrator: Compare plans on a normal year and a bad year, not just on the premium.

What you’ll learn

1. What you pay, and when

   You always pay the premium, sick or well. When you get care, many costs go toward the deductible first. After that, you pay a copay (a set fee) or coinsurance (a percent of the bill) until you reach the out-of-pocket maximum. Some visits have a copay from day one.

2. Your worst case: the out-of-pocket max

   The out-of-pocket maximum caps what you pay for covered, in-network care in a plan year. Add a year of premiums and you have your worst case. Out-of-network and uncovered care don’t count toward it. The legal ceiling on this cap is linked on a fact card.

3. Preventive care is often $0

   In-network preventive care, like a yearly checkup, many screenings and many vaccines, usually costs $0 on most plans, even before the deductible. Using it doesn’t make your plan cost more.

4. Total cost, and the network

   Comparing a quiet year and a bad year shows the real difference between plans. Before choosing, people check that their doctors are in the plan’s network and their medicines are covered. Care outside the network can cost far more.

   Example: Plan A totals $870 in a quiet year and $7,720 in a bad one. Plan B totals $2,550 and $6,520.

Key words

copay

a set fee you pay for a visit or a medicine

coinsurance

your percent of a bill after the deductible

out-of-pocket maximum

the most you pay for covered, in-network care in a year

network

the doctors and places a plan has deals with

Common questions

What if I buy my own plan instead of getting one through work?

The same math works. Marketplace plans list premiums, deductibles and out-of-pocket maximums the same way, and some people get help paying the premium based on income.

Remember this

Compare plans on a normal year and a bad year, not just the premium.

Try it: Test two plans on two kinds of year

1. Pick two health plans you can choose from.
2. Bad year: add a year of premiums to each plan’s out-of-pocket max.
3. Normal year: add a year of premiums to your usual care costs.
4. Check that your doctors and medicines are covered.

Do the two-year math on paper with your real plans’ numbers.

Live facts

Numbers that change over time, with when they were last checked and where they come from.

• This year’s legal ceiling on the out-of-pocket maximum

  Source: HealthCare.gov(opens in a new tab)

• Preventive care covered at no cost

  Source: HealthCare.gov(opens in a new tab)