Choosing a health insurance plan is one of the most important decisions you can make for yourself and your family. The right plan helps you stay healthy and financially protected, while the wrong one can lead to unexpected bills, limited access to care, or coverage gaps you didn’t expect. Asking the right questions before buying health insurance empowers you to make confident, informed decisions.
Use this guide to learn the essential questions to ask before choosing a health insurance plan—and why each one matters.
1. What Type of Health Plan Is This?
Health insurance plans fall into several categories, each with different rules on providers and referrals.
Common types include:
- HMO (Health Maintenance Organization)
- PPO (Preferred Provider Organization)
- EPO (Exclusive Provider Organization)
- POS (Point of Service)
Ask:
- Do I need a referral to see a specialist?
- Can I use doctors outside the network?
- What costs change if I go out-of-network?
Understanding the plan type helps you anticipate how flexible—or restrictive—your coverage will be.
2. What Are the Monthly Premiums?
Your premium is the amount you pay each month to keep your coverage active.
Ask:
- How much will I pay each month?
- Are there rate increases expected next year?
- Are there discounts for dependents or family plans?
Choosing a plan starts with understanding what you’ll pay consistently.
3. What Is the Deductible?
The deductible is the amount you must pay before your insurance begins covering many services.
Ask:
- What is the annual deductible?
- Does the deductible apply to prescriptions, labs, or imaging?
- Are preventive services exempt from the deductible?
A lower premium often means a higher deductible, so be sure the amount fits your budget.
4. What Are the Copays and Coinsurance?
Even after meeting your deductible, you will continue to share costs.
Ask:
- How much is the copay for doctor visits, specialists, and urgent care?
- What percentage will I pay for hospital services or procedures?
- Are mental health services covered with a copay or coinsurance?
These out-of-pocket costs directly impact your annual healthcare expenses.
5. What Is the Out-of-Pocket Maximum?
This is the most you will pay in a year for covered services.
Ask:
- What is the out-of-pocket maximum for individuals and families?
- What costs count toward this limit?
- Does the max reset annually?
Once you hit this limit, the plan pays 100% of covered services—making it one of the most important numbers in your policy.
6. Are My Current Doctors In-Network?
Network access is one of the biggest factors people overlook.
Ask:
- Are my preferred doctors and specialists in-network?
- Are local hospitals included in the network?
- What happens if I go out-of-network?
Out-of-network care can be significantly more expensive or not covered at all, depending on the plan type.
7. What Does the Plan Cover for Prescriptions?
Prescription coverage varies widely across plans.
Ask:
- Is my current medication on the formulary?
- What are the drug tiers and copays?
- Do specialty or brand-name drugs require prior authorization?
- Are generic alternatives encouraged or required?
Understanding prescription rules helps you plan for predictable medical expenses.
8. Are Preventive Services Covered at No Cost?
Most plans cover preventive care at 100% when using in-network providers.
Ask:
- Which preventive services are included?
- Are routine checkups, vaccines, and screenings fully covered?
- Are there age-based limitations for certain preventive services?
This helps you take advantage of free care that keeps you healthy.
9. What Does the Plan Cover for Mental Health Services?
Mental health benefits vary from plan to plan.
Ask:
- Are therapy and counseling sessions covered?
- What are the copays or coinsurance amounts?
- Are virtual mental health services included?
- Are there session limits?
Mental health access is essential, so review these details carefully.
10. Do I Need Prior Authorization for Certain Services?
Some services require insurer approval beforehand.
Ask:
- Which services require prior authorization?
- Who submits the authorization—the doctor or me?
- Could a lack of authorization result in denied claims?
Knowing these rules prevents unexpected bills.
11. Does the Plan Cover Emergency and Urgent Care?
Emergency care rules differ from urgent care coverage.
Ask:
- How is emergency care covered?
- Does the plan cover out-of-network emergencies?
- What are the copays for urgent care centers?
Emergencies are unpredictable—your plan should protect you when they happen.
12. Does the Plan Include Telehealth or Virtual Care Options?
Many plans now cover remote visits.
Ask:
- Are virtual doctor visits included?
- Is telehealth offered with no copay?
- Are mental health teletherapy services covered?
Virtual care can dramatically reduce costs and improve convenience.
13. How Are Medical Bills and Claims Handled?
Understanding the administrative process helps reduce stress.
Ask:
- How do I access my Explanation of Benefits (EOB)?
- How are disputed claims handled?
- How quickly are claims processed?
Knowing how to navigate claims ensures smoother communication with your insurer.
14. What Are the Plan’s Exclusions?
All health insurance plans exclude certain services.
Ask:
- What is not covered under this plan?
- Are alternative treatments covered (chiropractic, acupuncture, etc.)?
- Are cosmetic procedures excluded?
Reviewing exclusions prevents surprises later.
15. Are There Wellness Programs or Extra Benefits?
Many insurers offer added perks, such as:
- Gym membership discounts
- Nutrition or weight-loss programs
- Smoking cessation programs
- Nurse hotlines
- Health coaching
Ask which extras are included and whether they reduce your premium or out-of-pocket costs.
Final Thoughts
Buying health insurance is an investment in your well-being and financial security. Asking the right questions ensures you choose a plan that fits your medical needs, budget, and expectations. By reviewing deductibles, networks, drug coverage, cost-sharing, exclusions, and claim processes, you can confidently select a policy that supports your health today and in the future.
Smart consumers don’t just buy health insurance—they ask the right questions first.