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Health insurance shopping guide

Use these tips to shop smart for health coverage.

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If you’re looking for health care coverage, you're probably looking for traditional health insurance. This is also called major medical coverage, comprehensive coverage, or ACA-compliant coverage after the federal Affordable Care Act (ACA).

Traditional health insurance gives you financial protection from unexpected health care costs and helps you manage preexisting conditions.

Make sure you know what you’re buying. Some websites offer alternative health plans that have fewer benefits and more limits than traditional health insurance.

Also use our tips for finding a health plan and saving money.

You can use this checklist to help you decide on health coverage.

Print this checklist (PDF)

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Buying a plan on HealthCare.gov

  • All plans on HealthCare.gov are traditional health insurance.
  • The Texas Department of Insurance approves these plans and can help if you have a problem.
  • You can shop during open enrollment and special enrollment periods.
  • Plans will cover your preexisting conditions and provide other protections.
  • Be cautious shopping on other websites, since they might be selling limited plans or products that aren’t insurance. Those plans aren't subject to most state and federal regulations.

Using doctors, hospitals, and medications

  • Each plan has its own list of doctors, hospitals, and prescription drugs.
  • When you compare plans on HealthCare.gov, you can enter the names of the doctors and medications you use to see which plans cover them.
  • If the doctors or medications you use aren’t covered, ask yourself if the plan has doctors or medications that you’d be comfortable switching to.
  • Keep in mind:
    • The list of medications should stay the same during the year, but it might change each year when the plan renews.
    • The list of covered doctors and hospitals can change throughout the year if health plans and health care providers can't agree on a contract.
    • TDI reviews health plan networks to make sure they meet state requirements and include enough doctors and hospitals. If you can't find a doctor or hospital, tell the plan so they can help you find one at in-network prices.

Costs for a health plan

  • Most people who shop on HealthCare.gov qualify for a subsidy that lowers their monthly premium.
  • Know how much you’ll have to pay for these out-of-pocket costs:
    • Monthly premium (after any subsidy).
    • Deductible. This is the amount you have to pay before the health plan pays.
    • Services and treatments before you meet the deductible. Ask if primary care and telemedicine visits are free.
    • Copays. These are fixed amounts you pay for certain services. For example, an emergency room visit might have a $200 copay.
    • Coinsurance. This is the amount you pay after you’ve met your deductible. It’s a percentage of the cost of the service. For example, your health plan might pay 80% of the cost of a surgery. You pay the other 20%.
    • Out-of-pocket maximum. This is the limit on how much you may have to pay out-of-pocket for covered medical care.

Primary care and referral requirements

  • Most HMOs require you to select a primary care provider (PCP) and get a referral before seeing a specialist.
  • Make sure you understand the plan's requirements for getting care.
    • Networks. Ask if you have to use doctors, hospitals, and urgent care centers in the plan’s network or any that you want.
    • Referrals. Ask if you need a referral from your PCP before you can see a specialist.
    • PCP. Ask if your copay is lower if you use your designated PCP.

Avoid scams

Here are some warning signs that you might want to move on to another company.

  • The agent or salesperson can’t answer basic questions about the plan.
  • You feel pressured to decide right away. There are no limited time offers or special deals in health insurance.
  • A price that is much lower than other companies you’ve checked. This probably means the plan has fewer benefits and more limits.
  • You get a call or email from a company or person you didn’t contact first.

Need more help?

Call our Help Line at 800-252-3439 to see if a company is licensed, check their complaint history, or ask questions. You can also use our list of companies selling plans in Texas.

Resources

Questions? Call us at 800-252-3439.