How to Choose a Health Insurance Plan: 10 Things to Compare Before You Enroll

Premium: what you pay every month, period

Your premium is the amount you owe to keep coverage active, whether or not you use any care that month. Multiply the monthly figure by 12 to see the real annual cost before you compare it against anything else, since a small monthly difference adds up more than it looks on the surface. As covered in more detail in our guide to health insurance costs for 2027, the premium is only the starting point of what a plan actually costs you over a full year.

It's easy to fixate on the premium specifically because it's the number you see repeated everywhere during enrollment, and it's the one that hits your paycheck or bank account directly every single month. That visibility gives it outsized weight in a lot of people's decision-making, even though it represents only one part of the total cost picture the other nine factors on this list fill in.

Deductible: what you pay before insurance kicks in

Your deductible is the amount you pay out of pocket before your plan starts sharing costs for most services. Deductibles vary enormously by plan, commonly ranging from $0 on richer plans to well over $7,000 on leaner ones. A lower premium very often comes paired with a higher deductible, which is exactly why comparing these two numbers together, rather than either one alone, matters so much.

It's also worth checking whether a plan has separate deductibles for different categories of care, such as one deductible for medical services and a completely different one for prescription drugs. Some plans combine everything into a single deductible, while others split it, and this distinction can meaningfully change how quickly you actually reach the point where your plan starts sharing costs more generously.

Copays: fixed costs for specific services

A copay is a flat dollar amount you pay for a specific service, commonly $20 to $50 for a primary care visit and somewhat more for a specialist. Copays are predictable, which makes them easier to plan around than coinsurance, but they can still add up quickly if you or a family member sees several specialists regularly throughout the year.

Coinsurance: your ongoing percentage share

Coinsurance is the percentage of a covered cost you continue paying after your deductible is met, with your plan covering the rest. A plan with 20% coinsurance means you pay 20% of the remaining bill for a given service, and your insurer covers the other 80%, up until you reach your out-of-pocket maximum for the year. Two plans with an identical deductible can still leave you paying very different amounts overall depending on their coinsurance rate.

Out-of-pocket maximum: your annual ceiling

Once your combined deductible, copay, and coinsurance payments for the year reach your plan's out-of-pocket maximum, your insurer covers 100% of additional covered, in-network costs for the rest of the plan year. For 2026, the federal ceiling on ACA plans sits at $10,600 for an individual or $21,200 for a family, though many specific plans set their own limit below that. This number matters most in a genuinely bad health year, since it's the real cap on how much a serious illness or injury can cost you.

Provider network: is your doctor actually in it

Confirm your specific doctors, specialists, and preferred hospital are actually in-network under the exact plan you're considering, not just generally accepted by the insurance company. A single insurer can offer several genuinely different networks across its own plan lineup, so a provider accepting one of that company's plans doesn't guarantee they accept all of them. Checking directly with your provider's office, in addition to the insurer's online directory, is worth the extra few minutes, since directories aren't always perfectly current. As covered in our PPO vs. HMO comparison, network structure itself varies meaningfully by plan type as well.

This step matters even more if you're managing an ongoing condition with an established specialist relationship, since switching plans and discovering that specialist is now out-of-network can mean either paying significantly more or restarting care with someone new. Confirming network status before enrolling, rather than after your first bill arrives, is one of the most reliable ways to avoid this particular surprise.

Prescription drug coverage: check the actual formulary

Every plan maintains its own formulary, a specific list of covered drugs organized into cost tiers, and the same medication can sit on a cheaper tier under one plan and a far more expensive one under another. Don't assume a medication will be covered the same way next year simply because you're staying with the same insurance company, since formularies change annually even when your carrier doesn't. If you take regular prescriptions, look up each one specifically on a plan's current formulary before enrolling, rather than assuming standard coverage.

Beyond simply checking whether a drug is covered at all, look at which tier it falls under and whether the plan applies prior authorization, step therapy, or quantity limits to it. A medication that's technically covered can still come with real friction attached, and that friction is worth knowing about in advance rather than discovering it the first time you try to fill a prescription.

Plan type and metal tier

Plan type (HMO, PPO, EPO, or POS) determines your network rules and whether referrals are required, while metal tier (Bronze, Silver, Gold, or Platinum) determines the overall cost split between you and your insurer, based on actuarial value. These are two separate decisions layered on top of each other — a high-deductible plan and a low-deductible plan can both exist within the same network type, and vice versa, so it's worth evaluating each independently rather than assuming one determines the other.

Extra benefits: nice to have, not a reason to choose

Many plans offer supplemental extras like dental, vision, telehealth visits, or wellness program discounts. These are genuinely worth knowing about, and can meaningfully add value if you'll actually use them, but they shouldn't be the deciding factor between two otherwise different plans. A plan with a slightly weaker core benefit structure but a shiny extras package is rarely the better overall choice once the core numbers are compared honestly.

Total estimated annual cost: the number that matters

Add your annual premium to a realistic estimate of what you'll actually spend in deductible and coinsurance based on your expected healthcare use, and compare that combined figure across plans rather than any single line item alone. If you qualify for a premium tax credit, factor your actual subsidized premium into this total, not the sticker price. This single combined number is the most honest basis for comparing plans against each other.

Ten things to check before you enroll

• Calculate the full annual premium, not just the monthly figure.
• Confirm the deductible and how it applies to individual versus family coverage.
• Note the copay amounts for the specific services you use most often.
• Check the coinsurance percentage that applies after your deductible.
• Confirm the out-of-pocket maximum and what does, and doesn't, count toward it.
• Verify your specific doctors and hospitals are in-network for this exact plan.
• Look up your actual prescriptions on the plan's current formulary.
• Confirm the plan type and metal tier match how you actually want to access care.
• Note any extra benefits, but don't let them outweigh the core comparison.
• Add it all up into one total estimated annual cost before deciding.

Common questions about choosing a health insurance plan

Have a question that isn't answered below? Our full health insurance FAQ page covers more general coverage questions.