A Practical way to look beyond the monthly premium and choose coverage that fits your life. I cover this in more detail in "The Prepared Patient: Your Guide to Surviving the Health Care System".
Medicare open enrollment is not open. Soon, the ACA Marketplaces and employer-based plans will open for enrollment. Choosing health insurance may be one of the most consequential financial decisions you make all year. Yet many of us spend more time comparing a new phone than reviewing the details of a health plan.
I understand why. Insurance documents are dense, the language can be confusing, and plan differences are often hard to see until you need care. As a physician who has worked across the health care system, I have learned how much those overlooked details can matter to patients and families.
If you are reviewing coverage through your employer, the Health Insurance Marketplace, or Medicare, start with these five questions.
1. What could this plan cost me over an entire year?
The monthly premium is only one part of the picture. Also consider the deductible, copayments, coinsurance, and annual out-of-pocket limit. Then think about how you actually use care: regular prescriptions, primary care visits, specialists, therapy, lab work, or an ongoing medical condition.
Try comparing two scenarios. First, estimate a typical year with the care you expect to use. Next, consider a difficult year with an unexpected hospitalization or other major expense. The out-of-pocket maximum generally applies to covered services under the plan’s rules and may exclude premiums, noncovered care, and some out-of-network costs. Read the details carefully.
2. Can I see the doctors and use the hospitals I trust?
A familiar insurance company name doesn't guarantee your doctors participate in a particular plan. Networks can vary by product, location, and plan year. Check whether your primary care clinician, specialists, hospital, and preferred urgent care center are in network.
Use the plan’s provider directory, and then confirm directly with the clinician’s office and insurer when possible. Ask whether referrals are required, whether out-of-network care is covered, and what you would pay. If you or someone in your family has a complex condition, pay special attention to this step.
3. Are my prescriptions covered, and what will they actually cost?
Make a list of every medication you take, including the dose and preferred pharmacy. Compare that list with each plan’s formulary, the list of covered drugs. A medication may be covered but placed on a higher-cost tier. A plan may also require prior authorization, step therapy, or quantity limits.
Ask what you would pay at your usual pharmacy and whether a lower-cost pharmacy or mail-order option is available. If you take an expensive medication, a few minutes reviewing these details may reveal a major difference between plans.
4. What happens when I need care I did not anticipate?
Consider how the plan handles specialist visits, imaging, outpatient procedures, hospital stays, mental health care, rehabilitation, and home health services, as relevant to your needs. Which services require prior authorization? Who arranges it? What happens if your preferred specialist is unavailable?
These questions matter most when a new diagnosis changes your plans. Look for the plan’s Summary of Benefits and Coverage, along with any documents describing exclusions and authorization requirements.
5. Where can I turn if a bill or coverage decision seems wrong?
Save the member services phone number. Learn how to find an Explanation of Benefits (usually on your insurer's website or mailed to you), which explains how a claim was processed and is usually not a bill. Ask how to request a written explanation of a denial and what the appeal process requires. Appeal rights and deadlines depend on the coverage and situation, so follow the instructions that apply to your plan.
Keep records of calls, including dates, names, reference numbers, and promises of follow-up. Documentation can make a confusing problem easier to resolve.
A simple way to compare your options
Before you enroll, put your two or three leading plans side by side on one sheet. Write down the estimated annual premium, deductible, out-of-pocket limit, important doctors, prescriptions, referral rules, and potential obstacles. Circle anything you still need to verify. Then choose with the full picture in view.
For people with Medicare, annual open enrollment runs from October 15 through December 7, with most coverage changes taking effect January 1. Employer and Marketplace enrollment periods follow different schedules. Whatever your coverage, review the details for the coming plan year rather than assuming they stayed the same.
In my book, The Prepared Patient, I encourage readers to get organized before health decisions become urgent. Choosing insurance is a great place to start.
What is one detail about a health plan that you wish you had checked sooner? I would be interested to hear what you have learned.
About the author Terry Adirim, MD, MPH, is a physician and the author of The Prepared Patient: Your Guide to Surviving the Health Care System (Johns Hopkins University Press, 2026). Available on Amazon
Helpful resources for making a choice
HealthCare.gov, Your Total Costs for Health Care