How to choose the right health plan

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Finding the right health plan starts with knowing your options. There are three main types of plans that offer major medical coverage:

• Preferred provider (PPO) plans. PPOs have higher premiums but more flexibility in doctors. You might need preapproval for some procedures.
• Health maintenance (HMO) plans. HMOs have lower costs, but you’re limited to in-network providers, so make sure your doctors are in the network. You must choose a primary care physician who coordinates your care and usually need a referral to see a specialist.
• Exclusive provider (EPO) plans. EPOs are like HMOs without any out-of-network coverage. You don’t have to pick a primary care physician and can see specialists without a referral. Premiums are usually higher than HMOs but less than PPOs.

Be careful about limited benefit health plans. These may have lower premiums, but they aren’t comprehensive. They don’t meet Affordable Care Act standards and often don’t pay for preexisting conditions, like diabetes.

Other costs you might pay

When you see a doctor or get a health care service, you might need to pay some of the cost yourself until you reach your plan's out-of-pocket limit. These costs are the:

• Annual deductible.
• Copays for doctors and specialists.
• Prescription drug costs.
• Coinsurance.

Know if the plan meets your needs

To see if a health plan is right for you, read its Summary of Benefits and Coverage. This document lets you make a side-by-side comparison of the coverage in different plans. Start by reviewing what you will pay for the care you are likely to need – such as visits to your doctors or specialists, urgent care, and emergency rooms. Compare what the plan will cover before you meet the deductible. Also review the plan limits and exclusions.

Before you buy a plan, ask if your doctors and specialists are in their network and check that your prescription medications are covered. Ask how much you will pay each month to refill for your prescriptions.

When to sign up for a health plan

You can get a new health plan during open enrollment. If you’re shopping on HealthCare.gov, this is from November 1 to January 15. Enroll by December 15 to get coverage that starts January 1. Have an estimate of your annual income ready to see if you qualify for a credit to lower your monthly premium.

Even if you’re keeping the same health plan you had last year, check that you can still get the same benefits. These can change from year to year.

If you have a health plan through your job, ask for open enrollment dates from your company’s human resources department.

Special sign-up times outside of open enrollment

There are special enrollment periods for big life changes, like the birth or adoption of a child, marriage, or moving to a new state or country where your plan isn’t available. Sometimes your income changes and you might qualify for a tax credit that you didn’t qualify for before.

If you qualify for a special enrollment period, contact HealthCare.gov or your job’s human resources department.

Learn more about enrolling for a health plan on the Texas Insurance Podcast.

Learn more

• Before you buy an alternative health plan... (video)
• Use these tips to shop smart for health coverage.
• Health care coverage guide.
• How to apply and enroll.
• Alternative health plans.
• Know what kind of health insurance you’re buying.