Health insurance questions, answered

It’s the amount you pay for certain covered services before your plan starts sharing those costs. Some benefits have different rules. Check what your plan pays for before you reach the deductible.

A copay is a set dollar amount for a covered service. For example, your plan might charge $30 for a primary care visit. Check whether the deductible applies and whether tests ordered during the visit cost extra.

Coinsurance is your percentage of the plan’s allowed amount for a covered service. Suppose you’ve met your deductible, the allowed amount is $200, and your share is 20%. You would pay $40 in this example.

Your premium is what you pay to keep coverage active, usually each month. Budget for it even in months when you don’t receive care.

For Marketplace plans, this is the annual limit on what you pay toward covered in-network care under the plan’s rules. Premiums, noncovered services and most out-of-network costs do not count toward it.

A provider or facility is in-network when it has a contract with your specific plan. An insurer can offer several networks, so the company name alone won’t tell you whether your doctor participates.

It’s the plan’s list of covered prescription drugs. Check the exact drug, dose, cost tier, preferred pharmacies and whether approval is required.

Compare a typical year and a year when you need more care. Look at 12 months of premiums, the services you use regularly, and the plan’s out-of-pocket limit. Check the provider network and drug list alongside the costs.

Use the provider directory for the exact plan and coverage year. Confirm with the insurer and your provider’s office, including the location where you receive care.

Have your current plan information, any notice about a coverage change, and a list of doctors, medications and pharmacies you want to check. Keep personal details handy for the conversation rather than putting them into a website quiz.

Start with the doctors, prescriptions and monthly budget that matter to your household. Our individual and family coverage guide shows how to compare a typical year with a high-use year. To see plans for your ZIP code, preview plans and prices on HealthCare.gov. Your completed application determines eligibility for savings.

Ask your benefits office for the last day everyone on your policy will be covered. Losing qualifying coverage may open a Special Enrollment Period. Use our guide to changing individual coverage to prepare, then check the Marketplace’s special enrollment rules for your situation.

Ask your benefits administrator whether your coverage is based on current employment and which plan pays first. Then confirm your enrollment timing with Social Security before changing coverage. Our Medicare enrollment guide explains how work coverage and Part B fit together.

Part B helps pay for medical care such as doctor visits and outpatient services. Part D helps pay for prescriptions. When comparing drug plans, have your medication names, doses and preferred pharmacy handy. See how Parts A, B, C and D work together.

Start with your approximate employee count, work locations, target start month and monthly contribution budget. Ask which employees can participate and what information the carrier needs for a formal quote. Our first-time employer benefits guide walks through those decisions.

Ask for monthly rates by coverage tier, such as employee-only and family. For each tier, subtract the employer contribution from the premium to see the employee share. Multiply the business share by expected enrollment in each tier to estimate the monthly budget. Review what to compare in a group proposal.

Put the renewal and an alternative side by side using the same employee count and employer contribution. Compare payroll deductions, deductibles, prescription costs and access to local clinics. A lower premium may still mean employees pay more when they need care. Use the employer renewal checklist.

Ask for the provider directory and prescription drug list for each exact plan under consideration. Give employees the links so they can check their own clinics, locations and medications privately. Include the election deadline and a contact for questions in the enrollment guide. See what to include in employee enrollment materials.

If you’re buying coverage for yourself or your household, start with individual and family coverage. If you’re hiring and want to offer a benefit, use the employer guide to prepare questions about group eligibility.