Choosing a health insurance plan shouldn’t feel like decoding a secret language—but for many, it does.
The terminology is confusing. The options are overwhelming. And the consequences of choosing the wrong plan can be both financial and personal. Whether you’re navigating open enrollment, exploring options for the first time, or making a change due to life circumstances, one thing is certain: asking the right questions matters.
In this guide, we’ll explore the 10 most important questions you should ask before committing to a health insurance plan. Armed with these, you’ll be better equipped to make a confident and informed decision.
Why Asking the Right Questions Matters
In 2023, the average healthcare spending per person in the U.S. reached $14,570. For most Americans, health insurance is a major financial decision—one that impacts not just their wallets, but their access to care, peace of mind, and long-term well-being.
And coverage isn’t limited to just traditional health insurance anymore. When choosing a plan, you may encounter options such as:
Health insurance
Dental insurance
Vision insurance
Life insurance
Medicare and supplemental Medicare plans
Understanding what each plan includes, and how it aligns with your needs, is key.
1. What Type of Plan Is It (HMO, PPO, EPO, POS)?
The type of plan determines how you access care and how much flexibility you have in choosing providers.
For example, an HMO usually offers lower premiums but limits you to a specific network of doctors and requires referrals to see specialists. PPOs, on the other hand, give you more freedom to see out-of-network providers but often come with higher costs.
EPOs and POS plans each have their own combinations of access and referral requirements. Consider your lifestyle, how often you visit specialists, and whether you have trusted providers you'd prefer to keep seeing.
2. What Does the Plan Actually Cover?
Not all health plans cover the same services. While most plans include essential benefits like preventive care, hospitalization, maternity, mental health, and prescription drugs, the details can vary.
Some plans include extra services like acupuncture, chiropractic care, or fertility treatments. Others may exclude certain therapies or limit the number of visits. It’s important to review the summary of benefits and identify whether your needs—such as regular physical therapy or mental health counseling—are covered.
3. Are My Doctors and Hospitals In-Network?
If you have a preferred doctor or nearby hospital you trust, make sure they’re considered in-network. Out-of-network care often comes with significantly higher out-of-pocket costs—or might not be covered at all.
Double-check provider directories or call the provider’s office directly. Don’t rely solely on search tools that may be out of date.
4. What Will I Pay—Beyond Just the Premium?
It’s easy to focus on the monthly premium, but that’s only one part of the cost equation. Ask about:
Deductibles: How much you must pay before your plan begins to cover services
Copays and coinsurance: Your share of costs for visits, prescriptions, and procedures
Out-of-pocket maximums: The cap on your yearly expenses
Consider a scenario: a plan with low premiums might have a high deductible, meaning you'll pay thousands before coverage kicks in. Sometimes, paying a slightly higher premium results in lower overall spending—especially if you use your insurance regularly.
5. Are My Prescriptions Covered?
Your plan may not cover every medication. Each insurer maintains a formulary—a list of approved drugs, grouped by tiers. Tier 1 drugs usually have lower copays, while higher-tier or specialty drugs can be costly or require prior approval.
Review the plan’s drug list to see if your medications are included. If not, you may need to request an exception or consider switching to a different plan.
6. Do I Need Referrals to See a Specialist?
Some plans, like HMOs, require a referral from your primary care doctor before seeing a specialist. Others, such as PPOs, allow you to schedule directly.
If you manage a chronic condition or anticipate needing specialty care (like dermatology or physical therapy), this access can affect both cost and convenience. Think about how often you might need specialist services in the coming year.
7. How Is Emergency and Urgent Care Covered?
Emergency situations are unpredictable, and coverage can be tricky—especially when you’re away from home. Most plans will cover emergency care at any hospital, but follow-up care or post-emergency services may not be fully covered if out-of-network.
If you travel frequently, make sure your plan offers flexibility for urgent or emergency care across state lines.
8. Does the Plan Include Extras Like Dental, Vision, or Wellness Programs?
Many people overlook ancillary benefits that could save them money and improve their quality of life. Some plans bundle or offer discounts on:
Routine dental exams and cleanings
Vision screenings, glasses, and contacts
Gym memberships or weight loss support
Telehealth services
Even if these aren’t deal-breakers, they can add extra value—especially for families, older adults, or those managing lifestyle-related health issues.
9. How Does the Plan Treat Pre-Existing Conditions?
Under current federal law, insurance companies cannot deny coverage or charge more based on pre-existing conditions. However, that doesn’t mean every plan offers the same level of care or access to specialists for chronic conditions.
If you have ongoing health needs, look closely at whether your providers, medications, and necessary services are accessible and affordable under the plan.
10. What’s the Insurance Company’s Reputation Like?
Even the best coverage can be frustrating if the insurer has poor customer service or makes it difficult to file claims.
Look for online reviews, Better Business Bureau ratings, or customer satisfaction surveys. A responsive insurer can make a big difference when you're dealing with complex billing, denied claims, or unexpected changes.
Case Example: Making the Right Choice
Let’s say Jane, a freelance graphic designer in South Jersey, takes two medications, sees a therapist monthly, and travels frequently for work.
An HMO plan would save her money on premiums but limit her ability to access her therapist and require referrals.
A PPO plan would cost more upfront but allow her to continue with her therapist and provide nationwide coverage when she travels.
For Jane, the higher cost was worth the flexibility and continuity of care. Asking the right questions helped her avoid switching doctors mid-year or paying hundreds out-of-pocket.
Bonus: Tips for Open Enrollment Season
Open enrollment is your opportunity to make changes—don’t let it pass you by. Here are a few ways to make the most of it:
Make a list of your current doctors, prescriptions, and routine services
Estimate your expected medical needs for the year ahead
Use comparison tools to review multiple plans side-by-side
Consider bundling with dental or vision plans
Talk to a licensed health insurance agent for free advice
Conclusion: Ask Smarter, Choose Better
Choosing the right health insurance plan isn’t just about picking the cheapest premium. It’s about understanding how the plan fits into your life, your health needs, and your financial situation.
By asking the 10 questions above, you’re not just checking boxes—you’re taking control of your care.
Need help comparing plans or understanding your options?
Contact our team for personalized guidance on health, dental, vision, life insurance, and Medicare plans in Greater Philadelphia and South Jersey.
