Don’t kick the tires!


The purpose of this article is to help both the first-time buyer of a health plan and the seasoned enroller to find the best health plan to meet their needs.

As we approach ‘open enrollment’ (November 1st to December 15th), now is the time to review your past experiences and consider whether any change in circumstance means that you can choose a more affordable health plan, or that by changing your Health Insurance Agent you give yourself a wider choice of affordable health insurance.


You can, of course, go directly to a health insurance company but you will not benefit from any Federal or State subsidies or premium tax relief.  There some circumstances in which this may be the right option: but for most of us the better choice is to take advice from a Health Insurance Exchange, either Federal, State, or Private.

The Exchanges are independent advisors working on your behalf to secure affordable health insurance that best meets you and your dependents’ needs.  Federal and State exchanges deal only with health insurance.  Private exchanges can take a broader view and advise on supplementary insurances such as Dental, Vision, and Accident attracting favorable terms.

Now, you have chosen an agent

Your first question should always be: –

  • What do you (as a health insurance agent) need to know before you can advise me on the medical plan that is best for me and my dependents?
  • You should be prepared with your family details, ages etc. and the best information you have about your recent medical insurance history e.g. the need for visits to the doctor, regular prescriptions, pre-existing conditions and, if you know it, the approximate total spent.
    You should also advise your agent of any predictable events which might affect your insurance e.g. an addition to the family or an aging off at 26 or 65.

What type of plan do you suggest?

  • In most cases the answer will be, either an HMO or a PPO.
  • Don’t worry. This is health insurance jargon for Health Maintenance Organization or Preferred Provider Organization. The organization to whom your insurer will make payments for the agreed proportion of your expenses. The difference is that in an HMO you can only visit Doctors who are contracted to your insurer (in‑network) but you will be charged at the contracted (discounted) rate. If you choose a PPO you have the option to visit Doctors not contracted to your insurer (out of network), but you will be charged the full price.

I’d like to stay with my current provider. Is that possible?

  • Yes, it is entirely possible. You can renew your existing policy but if your Doctor is in more than one network, we can find the one that offers the best health plan for you (Either HMO or PPO) OR
  • We can find the most affordable health insurance plan (PPO) and you can visit your current family Doctor ‘off network’. But visits will cost you a little more. OR
  • If it is not so important to stay with your current Doctor we can find you a range of affordable health insurance plans with networks in your location (HMO or PPO). The choice is always yours.

What will my monthly premiums be?

  • It may seem obvious, but it is entirely down to you and your circumstances!
  • On balance, you should plan to commit 10% – 15% 0f household income to healthcare.
    • You may choose a low premium and a high personal exposure to the costs of services provided
    • You may choose to pay a higher premium and pay less of the service costs

 What is the deductible?

  • This is the health insurance industry equivalent of the ‘excess’ element of car insurance
  • It is the amount you pay ‘out of pocket’ before your insurance comes into play.
  • In principle the more you choose to pay ‘out of pocket’ the lower your monthly premium will be. Conversely, your monthly premium will be higher if you opt for a lower deductible
  • Your health insurance plan will step in as soon as your deductible has been exceeded and you will be liable for only the agreed share of the cost thereafter

 What do I get for my premium?

  • First you and your dependents have access to a ‘managed care’ system, usually an HMO or PPO
  • Under the Affordable Care Act (ACA) plan members are entitled to: –
    • Preventative care services which include screening for a number of common conditions
    • Counselling and vaccines
    • Preventative care benefits for women and children.
  • For a full list of the care and services see preventative healthcare services as outlined in
  • All health insurance plans available to consumers on the health insurance exchanges must cover the required services known as the ten essential benefits.

 What is a Co-pay?

  • Broadly speaking a Co-pay is one-time ‘admin fee’ for a visit to the Doctor, e.g. for a prescription.
  • Co-pays will vary depending on the service received and your insurer.
  • Co-pays do not usually count as deductible expenses. The cost of a prescribed medicine/treatment will be included in your deductibles. 

What is Co-insurance?

  • Co-insurance is all about sharing risk.  Your potential insurer will base their judgement on statistical data.  You must base yours on personal circumstances, expectations and affordability
  • The ‘metal plans’ give some indication of how the risk will be shared between you and your insurer:
    • Bronze           40/60
    • Silver 30/70
    • Gold                20/80
    • Platinum       10/90
    • They are a broad-brush estimate of the way in which costs will be shared.
    • They do not define the quality of service you will receive.(Check the star ratings of the plans you are considering)

Will pre-existing conditions affect my (our) acceptance on a plan?

  • If you enroll on the Health insurance marketplace you cannot be refused, or charged more, if you or any of your dependents has a pre-existing condition.  Depending on the insurer there may be an exclusion period. Your health insurance agent should clarify this.
  • You should be prepared to show records confirming the pre-existing condition.

If we travel on business or on vacation, are we covered?

  • If you travel regularly on business you should include this in your health plan.
  • If you take out of location vacations either in mainland USA or abroad you should consider specific short-term plans
  • Is the insurer you are recommending ‘A’ rated?

How does the plan you recommend score on the new CMS Quality Rating System?


With open enrollment on the horizon, make a copy of this blog. Fill in the blanks. Take it with you when you meet your Health insurance agent. Pin it on the wall if you are investigating ‘on-line’ or by phone.

Photo by Olya Kobruseva from Pexels

Don’t just kick the tires – ASK the QUESTIONS!

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