Health Insurance—How to Decide What Policy to Get?

Health insurance is not cheap, and it is tempting to avoid it, especially if you have never been ill. In fact, it is not uncommon for people in their 20s to skip out on health insurance because they believe they are healthy enough. It may seem promising to eliminate health insurance from your budget if you seldom visit the doctor, especially if finances are tight. 

Alternatively, you may pay for medical expenses as they arise rather than worrying about insurance premiums and co-payments. In the event of a serious illness, accident, or ongoing health condition,  however, this could be very challenging, as the costs can become astronomical. For this reason, having some form of health insurance is highly recommended. 

Types of Insurance Plans 

Most health insurance plans can fit into 1 of the following 3 categories 

• Health maintenance organizations (HMOs) 
• Preferred provider organizations (PPOs) 
• Indemnity, fee-for-service (FFS), or point-of-service (POS) Plans 

Each of these plans has its own purpose. However, their biggest difference lies in their network coverage and restrictions, their need for referrals, and how high or low their out-of-pocket costs are.  

Understand the 4 “metal” Tiers 

You may have noticed that you can get a Bronze, Silver, Gold, or Platinum grade of the same plan. These different tiers do NOT have anything to do with the quality of your medical care. All plan levels will cover the same essential benefits, and the type of health insurance you have will result in worse or better care.  

Instead, the tiers are correlated with their out-of-pocket costs. The “metal” represents how much your insurer will pay vs. how much you will have to pay out-of-pocket. You will notice that the lower the tier, the more the consumer will pay. The higher the tier, the more the insurer will be responsible for.  However, a bronze plan will be cheaper and more affordable to the average individual versus a Platinum tier.  

Here is the breakdown of consumer vs. insurer costs based on each metal level 

Bronze: 

• Consumer pays: 40% 
• The insurer pays: 60% 

Silver: 

• Consumer pays: 30% 
• The insurer pays: 70% 

Gold: 

• Consumer pays: 20%
• The insurer pays: 80% 

Platinum: 

• Consumer pays: 10% 
• The insurer pays: 90% 

Key Terms to Define 

When researching which health insurance plan is best for you, it is important to understand a few key terms. These terms will come in handy when it comes time to decide on what plan you are going to purchase. 

Premium: Health insurance premiums are the fixed amounts you must pay to the insurance provider periodically in exchange for insurance coverage. Premiums can be paid monthly, quarterly, half-yearly,  or annually. Keep in mind that several factors contribute to your premium, such as your age, whether you are a smoker or non-smoker, and whether you have any pre-existing conditions. 

Copay: Generally, a co-payment clause is part of a health insurance plan that entails paying a portion of the total hospital bill as part of a cost-sharing program. The policyholder will pay a percentage of the hospital bill, and the insurance company will cover the remaining amount. Although this reduces the premium, it does not affect the amount insured. 

Deductible: A deductible generally refers to the amount a policyholder must pay to the hospital before their insurance company processes their claim. After you have paid your deductible, your insurance company will either compensate you directly or directly to the hospital where you received medical care. 

Inclusions: One of the most critical health insurance terms you should be familiar with is inclusions. The insurance company will compensate you for the policy’s key features or benefits. For example,  hospitalization expenses, ambulance and surgery expenses, and other expenses related to treatment are common inclusions. 

Exclusions: You cannot receive compensation from the health insurance company for these items, also called policy limitations. These exclusions are mentioned in insurance policies. 

Note: These are just a few common terms. If you are unsure, it is always best to look up what a term means. This will help you with any confusion while purchasing a policy. 

Consider Your Family’s Needs 

When choosing a healthcare plan, consider your family’s needs. A healthcare plan should be tailored to your family’s needs. Knowing what plan(s) work best for your circumstances is key since coverage can change yearly. Consider any chronic illnesses your family members may suffer from, as well as their medication and care needs. Enrolling in separate plans may be more affordable if you have family members with vastly different healthcare needs.  

Ensure Your Medications are Covered

Keep a list of your prescriptions and note if they are name-brand or generic. Patented or name-brand drugs can be costly, so finding a policy that covers them is important. However, generic drugs are generally more affordable and equally effective. Therefore, if your prescriptions are mostly generic, you may be able to find a more affordable plan OR be more comfortable paying out of pocket for your medication. 

Keeping in mind that many policies only provide full coverage for generic medication brands is a very significant aspect to bear in mind. Hence, if you rely heavily on name-brand medications, purchase a  policy that covers both name-brand and generic drugs.  

Consider Premiums, Copay, and Deductibles 

Insurance plans come with several out-of-pocket costs, each of which is critical to keep in mind when choosing a policy. For example, you pay a premium for your coverage, regardless of the services you use.  Co-payments, on the other hand, are fixed fees for certain kinds of office visits, prescriptions, and other kinds of care and are payable at the time of service. 

Additionally, you should take into consideration the costs associated with your deductible. The deductible you choose should never cause you great financial stress if you need to pay it. However, a  higher deductible may be the way to go if you have far more coverage than you will likely use in a year.  Higher deductibles result in lower premiums; make sure it isn’t higher than you could ever afford. Keep in mind there are also out-of-pocket maximums in many plans: Once you reach this amount, your insurance will cover any remaining expenses. 

Out-of-pocket costs can be challenging to manage and can be detrimental to your budget. You must consider what services you may require in the coming year before choosing a plan. Once you have identified which services you are interested in, analyze the associated costs under each plan you are considering. This can help you find one that works best for your needs and budget. 

Check Your Provider Networks 

If you or your family are planning to use doctors, specialists, or even a specific hospital, clinic, or pharmacy in the next year, write down all the providers you think you need. Then, make sure that you review each of the plans you are considering during open enrollment to ensure that the options meet your preferences. 

Additionally, there is a tendency for medical professionals, as well as insurance companies, to update  their contracts continuously. For example, a doctor or other professional who was in-network last year might be out-of-network the following year. Therefore, it is wise to stay updated on your annual policy changes. 

Average Cost of Florida Health Insurance 

Despite the high insurance cost, it remains an essential component of a healthy lifestyle. In Florida, the average cost of health insurance is $393 per month. While this average is beyond most people’s budgets, most employers offer health insurance at a less expensive rate. The average cost of health insurance through an employer is roughly $650. In reality, the employee pays only about $150, making it more affordable.

Depending on the type of coverage you choose, the deductible, the region, and the size of your family,  the cost of your insurance policy will vary greatly. Suppose you are unable to afford health insurance. In that case, you may wish to consider enrolling in a government-run program such as Medicaid or  Medicare. 

The Final Word 

Finding a policy that works for your entire family can be challenging. Choose one that covers all the essentials and any additional care and medications you may need while still staying within your budget.  This may seem like a lot and can be very overwhelming. The good news is that you can find lots of resources to assist you in understanding your different policy options. Furthermore, you can also speak directly to a healthcare insurance provider who can help formulate the most appropriate plan to meet your needs.