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Free Download: Comparing Plans Spreadsheet
Health care coverage plans can vary widely in cost, coverage, provider access, and rules for receiving care. Looking closely at these differences can make it easier to compare options and identify the plan that best fits medical needs, household circumstances, and budget.
Review Costs, Coverage, and Plan Details
Start by gathering all plan materials in one place. There may be pamphlets, brochures, or digital documents describing each plan. Lying them side by side makes it easier to compare key details.
Begin with premiums and deductibles. The premium is the amount paid each month to maintain coverage. For most services, the deductible must be met before insurance begins to pay.
Next, review copays and coinsurance. Compare what will be owed for services such as office visits, tests, and inpatient and outpatient hospital care, and how those costs are shared between the enrollee and the plan.
Another important consideration is the out-of-pocket maximum, also known as the MOOP. This is the most that must be paid in a plan year for covered services, not including premium costs. It typically includes spending on deductibles, copays, and coinsurance. Many plan years end on December 31st, regardless of when coverage begins. For example, if coverage starts on October 1st, a new deductible and MOOP may apply beginning January 1st.
It is also important to review the plan’s prescription coverage. Are regularly used medications covered? If the plan uses medication tiers, where do those prescriptions fall in the cost structure? This will affect how much will be paid each time a prescription is filled. It is also worth checking whether a local pharmacy can be used or whether mail-order services are required.
Evaluate Provider Access and Plan Flexibility
Review the provider network for each plan. Does it include preferred doctors and hospitals? Is care covered outside of the local area or state?
Plan rules can also affect how care is accessed. Some plans require referrals to see specialists or prior authorization before certain services are approved. Others offer more flexibility in how and where care is received.
For example, HMO-type plans often limit care to a defined geographic area and a network of providers, while PPO-type plans typically offer more options, such as a national network.
Once these details have been gathered, creating a simple chart or list can make it easier to compare key features across plans. The Asclepius Initiative has created a free downloadable spreadsheet for this purpose.
It is also important to consider total costs across different scenarios, such as having few medical needs, developing a chronic condition, or experiencing an acute health problem. Looking beyond the monthly premium to considering potential out-of-pocket costs over the course of the year provides a clearer picture of the overall cost and value of each plan.
Putting It All Together
Health care coverage decisions involve more than just picking the plan with the lowest monthly premium. Differences in deductibles, out-of-pocket costs, provider access, and plan rules can significantly affect both access to care and total spending over the duration of the policy.
Comparing plan details side by side helps to identify potential gaps in coverage, unexpected costs, or limitations on where and how care can be received. Taking the time to review these factors can help ensure that a plan aligns with both current and projected health care needs and financial circumstances, so that coverage is more likely to work as expected when it is needed most.
These materials were supported by funds made available by the Kentucky Department for Public Health’s Office of Population Health from the Centers for Disease Control and Prevention, National Center for STLT Public Health Infrastructure and Workforce, under RFA-OT21-2103.
The contents of these materials are those of the authors and do not necessarily represent the official position of or endorsement by the Kentucky Department for Public Health or the Centers for Disease Control and Prevention.