5 Key Factors to Consider Before Selecting a Health Insurance Plan

Have you ever wondered why getting health insurance quotes is so important? Millions of people have faced difficulties paying for medical expenses, especially between jobs. Even those with health insurance may still have co-pays for prescriptions or out-of-pocket costs after their insurance covers what the policy dictates. According to the Centers for Medicare & Medicaid Services (CMS), national health spending in the United States reached $4.9 trillion in 2023, underscoring just how significant healthcare costs have become for American families. Before you make a final decision on which health insurance to choose, here are five key things you should know:

1. What Type of Plan Are You Considering?

As you research health insurance quotes, you’ll notice that each insurance company offers something different. It’s essential to compare the plans carefully before making a financial decision. Consider how the policy meets your needs and those of your family. Health insurance is a crucial financial decision, so make sure the plan covers medical expenses, prescriptions, surgeries, and other important areas. Also, check what your insurance will cover after a medical procedure, such as follow-up therapy. These details are critical to ensure your plan meets all your healthcare needs.

Understanding the structure of each plan type is the first step toward making a confident decision. The four most common plan types available through employers and the ACA marketplace are:

Major insurers such as UnitedHealth Group, Anthem (now Elevance Health), Aetna, Cigna, and Humana each offer variations of these plan types with different premium structures, deductible tiers, and network sizes. When comparing quotes, pay close attention to the plan’s Summary of Benefits and Coverage (SBC) document, which all insurers are required to provide under the Affordable Care Act (ACA).

2. What Does Your Policy Cover (or Not)?

Different health insurance plans cover varying services. While some policies might cover physical therapy, others may only cover inpatient therapy, which is provided in the hospital. Similarly, your employer’s insurance plan might not cover pharmacy benefits. Most plans do offer prescription coverage, but not all medications may be included. For example, some plans do not cover asthma inhalers and may charge $50-$70 for them. If certain medications or treatments are important to you, make sure the plan includes them.

Under the ACA, all marketplace-compliant plans must cover ten categories of essential health benefits (EHBs). These include emergency services, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services, laboratory tests, preventive and wellness services, and pediatric services. However, the depth of that coverage — meaning how much you pay for each service — varies significantly between plans. The HealthCare.gov essential benefits overview provides a full breakdown of what marketplace plans must include.

One area where coverage gaps frequently surprise enrollees is prescription drug formularies. Each plan maintains a drug formulary — a tiered list of covered medications. Tier 1 drugs (generic medications) typically cost $5–$20 per fill, while Tier 4 or Tier 5 specialty drugs can carry co-pays of $100–$500 or more per fill, even with insurance. The FDA’s approved drug database can help you verify whether a specific medication is available in generic form, which may affect your tier placement and out-of-pocket cost.

Mental health parity is another critical coverage consideration. Under the Mental Health Parity and Addiction Equity Act (MHPAEA), insurers are required to cover mental health and substance use disorder benefits at the same level as medical and surgical benefits. If you or a family member relies on therapy, psychiatric care, or medication-assisted treatment, verify that your plan complies fully with MHPAEA requirements before enrolling.

3. How Much Does Your Plan Cost?

The cost of your health plan is a critical factor to consider. You need to balance coverage with affordability. Whether the plan is through your employer or purchased independently, it should fit your budget while offering the coverage you need. Review the full list of what the plan covers, and if it aligns with your needs and your budget, you can feel confident in your choice.

Health insurance costs are composed of several distinct components that work together to determine your total annual healthcare spending. Understanding each one is essential before committing to a plan:

Premium: The monthly amount you pay to maintain coverage, regardless of whether you use any healthcare services. For ACA marketplace plans in 2026, the average benchmark silver plan premium for a 40-year-old is $497 per month before subsidies, according to KFF’s 2026 marketplace premium analysis.

Deductible: The amount you pay out of pocket before your insurance begins sharing costs. The average individual deductible for an employer-sponsored plan is $1,787 per year, per the KFF Employer Health Benefits Survey.

Co-pay: A fixed dollar amount you pay for specific services, such as $30 for a primary care visit or $60 for a specialist visit.

Coinsurance: The percentage of costs you share with your insurer after meeting your deductible — commonly 20% for the enrollee and 80% for the insurer under a standard 80/20 plan.

Out-of-Pocket Maximum: The annual ceiling on what you will pay. Once reached, your insurer covers 100% of covered services. For 2026, the ACA-mandated cap is $9,200 for individuals and $18,400 for families.

If you purchase insurance independently through the ACA marketplace, you may qualify for Premium Tax Credits (PTCs) that reduce your monthly premium based on your household income relative to the Federal Poverty Level (FPL). The IRS premium tax credit guidance explains eligibility thresholds and how to claim this benefit on your federal tax return.

4. Can You Keep Your Current Doctors?

If you’ve been seeing the same doctor for a particular condition, it’s important to know if you can continue seeing them under your new plan. Always check whether your preferred doctors are included in the new insurance network. When you switch jobs or get a new insurance card, call your doctor’s office to confirm if they accept the new insurance. In larger medical practices, some doctors may not be covered by your plan, even if others are. Double-check this to avoid unexpected surprises.

Provider network accuracy is a well-documented problem in the health insurance industry. A landmark study found that a significant share of provider directories maintained by major insurers contained inaccurate or outdated information — listing physicians as in-network when they had left the network or were not accepting new patients. The CMS provider directory accuracy guidance outlines the standards insurers must meet, but verifying directly with your physician’s billing office remains the safest approach.

Balance billing — sometimes called surprise billing — is a related concern. This occurs when an out-of-network provider charges you the difference between their billed rate and what your insurer pays. The No Surprises Act, which took full effect in 2022, protects patients from most unexpected balance bills in emergency situations and from out-of-network providers at in-network facilities. However, understanding the limits of this protection is important, particularly for planned procedures where you have time to verify network participation in advance.

When assessing network adequacy, consider not just your primary care physician but also any specialists you see regularly, your preferred hospital system, urgent care clinics you use, and any behavioral health providers. A plan’s network may be labeled “broad” or “national,” but coverage can still vary significantly by specialty and geographic area. Tools offered by insurers such as UnitedHealth Group’s online provider finder, Aetna’s DocFind, and Cigna’s provider directory allow you to search in-network providers before enrolling.

5. What Is “Availing Care” and How Much Will It Cost?

“Availing care” refers to treatments or services that a patient might need or benefit from. For example, a doctor might recommend certain tests or therapies during an appointment. These recommendations are then reviewed by the insurance company to determine if they are necessary and covered. In some cases, a medical board may review the necessity of the care to decide if the insurance will pay for it. Knowing whether certain treatments are covered helps you plan for any additional costs.

The formal process behind this review is called prior authorization (sometimes written as “pre-authorization” or “pre-approval”). Prior authorization requires your healthcare provider to obtain approval from your insurer before delivering certain services, medications, or procedures. According to the American Medical Association (AMA), prior authorization requirements have increased substantially over the past decade, with physicians reporting that the process frequently delays necessary care and creates significant administrative burdens.

Common services that frequently require prior authorization include MRI and CT scans, specialty medications, outpatient surgery, physical and occupational therapy beyond an initial number of visits, mental health intensive outpatient programs, and certain diagnostic laboratory tests. Before undergoing any planned procedure, confirm with both your physician’s office and your insurer whether prior authorization is required — and obtain written confirmation of approval before the service is rendered.

If your insurer denies coverage for a recommended service, you have the right to appeal. Under the ACA, all marketplace plans must provide an internal appeals process and, if the internal appeal is unsuccessful, access to an independent external review. The U.S. Department of Labor’s (DOL) appeals guidance outlines your rights and the timelines insurers must follow when processing appeals.

Additional Factors That Can Affect Your Health Insurance Decision

Beyond the five core factors above, several additional considerations can significantly affect the value and performance of your health insurance plan. Taking time to evaluate these before enrollment can prevent costly surprises throughout the plan year.

Understanding Enrollment Windows and Special Enrollment Periods

You can only enroll in or change a marketplace health insurance plan during specific windows. The annual Open Enrollment Period (OEP) for ACA marketplace plans in most states runs from November 1 through January 15. Outside of this window, you must qualify for a Special Enrollment Period (SEP) triggered by a qualifying life event — such as losing job-based coverage, getting married, having a child, or moving to a new coverage area. The HealthCare.gov SEP eligibility guide provides a complete list of qualifying events and their documentation requirements.

Missing the enrollment window can leave you without coverage for an entire year or force you into a short-term health plan, which does not carry ACA protections and may exclude coverage for pre-existing conditions. Tracking your enrollment deadlines is as important as the plan selection itself.

How Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) Can Reduce Your Costs

If you enroll in a qualifying HDHP, you become eligible to open a Health Savings Account (HSA). HSAs are triple-tax-advantaged accounts: contributions are tax-deductible, earnings grow tax-free, and withdrawals for qualified medical expenses are tax-free. For 2026, the IRS allows HSA contributions of up to $4,300 for individuals and $8,550 for families, with an additional $1,000 catch-up contribution for those age 55 and older, per IRS Publication 969.

Unlike a Flexible Spending Account (FSA), HSA funds roll over indefinitely from year to year and remain yours even if you change jobs or insurers. Financial planning platforms such as Fidelity Investments and Vanguard now offer HSA investment options, allowing long-term account holders to grow their balance as a supplemental retirement healthcare fund. This makes the HDHP-plus-HSA combination an increasingly strategic choice for younger, healthier individuals who can afford to absorb higher deductibles in exchange for lower premiums and long-term tax savings.

Evaluating Plans Through the ACA Metal Tier System

ACA marketplace plans are categorized into four metal tiers — Bronze, Silver, Gold, and Platinum — based on how costs are split between you and your insurer. These tiers are designed to help consumers compare plans at a standardized level of cost-sharing.

Bronze plans cover approximately 60% of average healthcare costs, leaving the enrollee responsible for roughly 40%. Silver plans cover about 70%, Gold plans cover approximately 80%, and Platinum plans cover around 90%. Silver plans hold a unique advantage: they are the only tier eligible for Cost-Sharing Reductions (CSRs), which lower your deductible, co-pays, and out-of-pocket maximum if your household income falls between 100% and 250% of the Federal Poverty Level. The KFF subsidy explainer provides a clear breakdown of how CSRs work and who qualifies.

Medicaid and CHIP: Coverage Options for Lower-Income Individuals and Families

If your household income falls below a certain threshold, you may qualify for Medicaid or the Children’s Health Insurance Program (CHIP) rather than a marketplace plan. As of 2026, Medicaid eligibility in expansion states covers adults with incomes up to 138% of the Federal Poverty Level — approximately $20,783 per year for an individual. Medicaid is administered jointly by states and the federal government under the oversight of the Centers for Medicare & Medicaid Services (CMS), with eligibility rules varying by state.

CHIP provides low-cost or free coverage to children in families that earn too much to qualify for Medicaid but cannot afford private insurance. In most states, CHIP covers routine checkups, immunizations, doctor visits, prescriptions, dental and vision care, and emergency services. The Medicaid.gov CHIP resource center allows families to check eligibility and apply in their state.

Final Thoughts

Getting health insurance quotes helps you understand what to expect from your policy. Knowing what your plan covers, what it costs, and what it doesn’t include allows you to prepare for any potential medical expenses. As you explore different plans, make sure to ask questions, take notes, and consult trusted sources for advice. The more informed you are, the better equipped you’ll be to make a decision that benefits both your health and your finances.

Doing thorough research is one of the best ways to ensure you understand how insurance works and how to maximize its benefits. By knowing what to look for, you’ll be able to choose the right policy with confidence. As of April 29, 2026, the health insurance landscape continues to evolve, with regulatory changes from the U.S. Department of Health and Human Services (HHS), updated subsidy structures, and expanding telehealth coverage all affecting what plans offer and what they cost. Staying current with guidance from authoritative sources — including the National Association of Insurance Commissioners (NAIC), the Consumer Financial Protection Bureau (CFPB) for financial planning considerations, and state-specific insurance commissioners — will help you navigate annual enrollment decisions with greater confidence.