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Finding health insurance you can afford is about more than the monthly price

Finding health insurance you can afford is about more than the monthly price

If you're shopping for health insurance, one number usually jumps out first: the monthly premium.

It makes sense. You know what leaves your bank account every month, and you know what your budget can handle. So you might look at two plans and think, "This one is $100 less a month. Easy decision."

Maybe. But before you choose, there's a better question:

Mujer joven sentada en su mesa de comedor buscando seguro de salud asequible en su laptop

What will this plan actually cost me when I need care?

What will this plan actually cost me when I need care?

A lower-premium plan can mean higher costs when you see a doctor, fill a prescription or face unexpected care. A higher-premium plan may mean lower costs when you actually use healthcare.

Neither is automatically better. The goal is to find the plan that fits you, your health and your budget.

Here's how to think it through.

What will health insurance really cost you?

What will health insurance really cost you?

The premium is only one piece. Understanding the full picture can help you avoid surprises.

If you're wondering... Look at...
What do I pay to have coverage? Monthly premium
What might I pay when I use it? Deductible, copays and coinsurance
What's the most I could pay for covered care in a difficult year? Out-of-pocket maximum
What's this plan likely to cost me overall? Estimated total annual cost

What is a health insurance premium?

Your premium is the amount you pay each month to keep your coverage active - whether you use healthcare that month or not.

What is a health insurance deductible?

Your deductible is the amount you generally pay for certain covered services before your plan starts sharing costs. For example, if your deductible is $2,000, you may pay the first $2,000 of applicable covered expenses before your plan begins sharing those costs.

What are copays?

A copay is a fixed amount you pay for certain covered healthcare services. For example, your plan might have one copay for a primary care visit and another for a specialist visit. The amount depends on your plan.

What is coinsurance?

Coinsurance is your percentage of the cost of a covered service, generally after you've met your deductible. If your plan pays 80% of an applicable covered expense and your coinsurance is 20%, you would pay $20 of a $100 allowed cost.

What is an out-of-pocket maximum?

Your out-of-pocket maximum is the most you'll generally pay for covered services that count toward that limit during a plan year. After you reach it, your health plan typically pays 100% of applicable covered services for the rest of the plan year. This number is easy to overlook - and important to know.

If some of these terms are new to you, Florida Blue has resources that can help you make sense of the language before you compare plans.

View the full health care glossary

A lower premium can look attractive. But if it comes with a much higher deductible or higher cost sharing, you could pay more overall if you need care. That's why the real goal isn't necessarily finding the lowest premium. It's finding the best overall value for your situation.

What does “best value” actually look like?

What does “best value” actually look like?

Cost Plan A Plan B
Monthly premium $200 $350
Annual premium $2,400 $4,200
Deductible $5,000 $1,000
Doctor visit copay $25 $40
Out-of-pocket maximum $5,000 $3,000

At first glance, Plan A looks like the obvious bargain. You're paying $150 less every month. But suppose you end up needing significant healthcare during the year. Suddenly, the lower deductible and lower out-of-pocket exposure of Plan B could make the higher monthly premium worthwhile.

That's the tradeoff you're really trying to understand.

Learn how to choose a health insurance plan

How do you choose the right balance between cost and coverage?

How do you choose the right balance between cost and coverage?

Everyone's healthcare needs are different. The best plan for someone who mostly needs preventive care can be very different from the best plan for someone who sees specialists regularly, takes several prescriptions or expects a procedure in the coming year.

So before you compare plans, think about your own situation.

  • Did you mostly go to the doctor for preventive care last year, or did you have several appointments?
  • Do you regularly see a specialist?
  • Do you take prescription medications?
  • Are you expecting surgery, ongoing treatment, maternity care or another significant healthcare need?
  • How important is it to keep your current doctors?
  • How comfortable would you be with an unexpected healthcare expense?

Your answers can change what "affordable" means for you.

Which of these sounds most like you?

  • "I don't use much healthcare, and keeping my monthly payment low matters most."

    You may want to pay particular attention to the premium, deductible and out-of-pocket maximum. A lower-premium plan may fit your monthly budget, but make sure you're comfortable with what you could owe if something unexpected happens.

  • "I see doctors regularly or take prescriptions."

    Look beyond the premium. Consider your expected annual costs, copays or coinsurance, prescription coverage and whether your doctors and pharmacy are in the plan's network.

  • "I really don't like unexpected expenses."

    Predictability may matter more to you than having the lowest possible premium. Compare deductibles and out-of-pocket maximums carefully and think about how much financial risk you're comfortable taking on.

  • "Keeping my current doctors is important."

    Cost isn't the only consideration. Make sure the providers you want to see participate in the plan's network. Going out of network can mean paying more and, depending on the plan, some services may not be covered outside the network except in certain circumstances.

  • "I take several medications."

    Check the plan's prescription drug coverage and pharmacy network. A plan with a slightly higher premium could potentially make more sense if it provides better coverage for medications you use regularly.

  • "I expect a procedure or significant care this year."

    Try to think in terms of total expected cost, not just premium. Consider the deductible, copays, coinsurance and out-of-pocket maximum along with your monthly payment.

  • "I don't use much healthcare, and keeping my monthly payment low matters most."

    You may want to pay particular attention to the premium, deductible and out-of-pocket maximum. A lower-premium plan may fit your monthly budget, but make sure you're comfortable with what you could owe if something unexpected happens.

  • "I see doctors regularly or take prescriptions."

    Look beyond the premium. Consider your expected annual costs, copays or coinsurance, prescription coverage and whether your doctors and pharmacy are in the plan's network.

  • "I really don't like unexpected expenses."

    Predictability may matter more to you than having the lowest possible premium. Compare deductibles and out-of-pocket maximums carefully and think about how much financial risk you're comfortable taking on.
     

    "I really don't like unexpected expenses."

    Predictability may matter more to you than having the lowest possible premium. Compare deductibles and out-of-pocket maximums carefully and think about how much financial risk you're comfortable taking on.

  • "Keeping my current doctors is important."

    Cost isn't the only consideration. Make sure the providers you want to see participate in the plan's network. Going out of network can mean paying more and, depending on the plan, some services may not be covered outside the network except in certain circumstances.

  • "I take several medications."

    Check the plan's prescription drug coverage and pharmacy network. A plan with a slightly higher premium could potentially make more sense if it provides better coverage for medications you use regularly.

     

    "I take several medications."

    Check the plan's prescription drug coverage and pharmacy network. A plan with a slightly higher premium could potentially make more sense if it provides better coverage for medications you use regularly.

  • "I expect a procedure or significant care this year."

    Try to think in terms of total expected cost, not just premium. Consider the deductible, copays, coinsurance and out-of-pocket maximum along with your monthly payment.

Instead of asking "Which plan is cheapest?" ask: "Which plan gives me the best balance between what I can comfortably pay every month and what I might have to pay when I need care?"

What are the differences between Bronze, Silver, Gold and Platinum plans?

What are the differences between Bronze, Silver, Gold and Platinum plans?

If you're shopping for Marketplace coverage, you've probably seen plans labeled Bronze, Silver, Gold and Platinum.

Those names can make it sound as though Platinum is "better" coverage than Gold, Gold is "better" than Silver, and so on. That's not what the metal levels mean.

They describe, in general, how costs are split between you and your health plan - not the quality of the healthcare you receive.

  Bronze Silver Gold Platinum
Monthly premium Generally lower Generally moderate Generally higher Generally highest
Costs when you need care Generally higher More balanced Generally lower Generally lowest
Worth exploring if... Keeping monthly costs down is a priority and you expect less healthcare use You want more balance between monthly and out-of-pocket costs You expect to use more healthcare and are comfortable paying more each month You usually use a lot of care and prefer paying more each month in exchange for lower costs when you receive care
  Bronze Silver Gold Platinum
Monthly premium Generally lower Generally moderate Generally higher Generally highest
Costs when you need care Generally higher More balanced Generally lower Generally lowest

Worth exploring if...		 Keeping monthly costs down is a priority and you expect less healthcare use You want more balance between monthly and out-of-pocket costs You expect to use more healthcare and are comfortable paying more each month You usually use a lot of care and prefer paying more each month in exchange for lower costs when you receive care

Exact costs, benefits and available options vary by plan, and not every metal level may be available in every area or from every insurer.

This isn't about picking the "best" metal. It's about finding a way of sharing healthcare costs that fits your circumstances.

Learn more about the ACA and metal levels

Could you qualify for financial help?

Could you qualify for financial help?

Before you give up coverage just to lower the monthly price, check whether financial assistance may be available. Depending on your circumstances, you may qualify for help that lowers what you pay for Marketplace coverage.

  • Premium tax credits that reduce your monthly premium.
  • Cost-sharing reductions that can lower deductibles, copays and coinsurance for eligible consumers enrolled in qualifying Silver plans.

Many people assume they won't qualify. It's worth checking rather than guessing. Financial assistance can change both the plans you're able to consider and what those plans actually cost you.

Because eligibility requirements and amounts can change, use current information when you're shopping rather than relying on an old income threshold or dollar amount.

Saving money isn't only about the plan you buy

Saving money isn't only about the plan you buy

Choosing coverage is one financial decision. Knowing how to use your coverage is another.

A few habits can help you get more value from whichever plan you choose.

  • Stay in network when you can

    Health plans negotiate rates with doctors, hospitals and other providers in their networks. Using in-network care generally helps you get the most value from your coverage. If keeping a particular doctor is important to you, check the network before enrolling.

  • Check your prescription coverage

    If you take regular medications, confirm that they're covered and understand what you may pay. Ask whether generic or other lower-cost alternatives are available when appropriate, and check whether your preferred pharmacy is in network.

  • Use preventive care

    Depending on your plan and the service, certain preventive care may be available without additional out-of-pocket cost when requirements are met. Don't skip care that can help identify health issues earlier simply because you're trying to save money.

  • Choose the right place for care

    Not every health issue requires the same level of care. When it's medically appropriate, understanding your options - such as virtual care, primary care, urgent care and emergency care - can help you make more informed decisions about both care and cost.

  • Know before you go

    For planned care, ask questions before the appointment or procedure. Is the provider in network? Is the service covered? Does it require prior authorization? What might you be expected to pay? The more you know beforehand, the less likely you are to be surprised afterward.

What if you receive an unexpected medical bill?

What if you receive an unexpected medical bill?

Even when you choose your plan carefully and try to understand your costs, a bill can arrive that you weren't expecting. That can be frustrating - especially when you thought your insurance would cover more. Before assuming the amount is correct or that you simply have to pay it, slow down and figure out what happened.

My medical bill seems too high. How do I know whether my insurance covered what it should?

Start by comparing the medical bill with your Explanation of Benefits (EOB) or Member Health Statement (MHS), or EOB. An EOB/MHS isn't a bill. It's a statement from your health plan that explains the claim, including what services were submitted, what the plan paid and what you may be responsible for paying.

Look for services you don't recognize, duplicate charges, amounts that don't match what you expected, a provider you thought was in network but appears to have been treated differently, or a service that wasn't covered the way you expected. If something doesn't make sense, ask questions before assuming the bill is correct.

What if I don't understand my EOB/MHS?

You're not alone. Start with three questions: What was billed? What did my plan pay or allow? What does it say I may owe? Compare that amount with the bill you received from the provider. If the numbers still don't make sense, use the contact information provided on your EOB/MHS or contact Florida Blue for help understanding how the claim was processed.

What if I was charged for out-of-network care I wasn't expecting?

First, verify the provider's network status and how the claim was processed. Sometimes care can involve more than one provider - even when you went to an in-network facility. Ask your health plan and the provider's billing department which provider submitted the charge, whether that provider was in network, why the claim was processed the way it was, and what options you have if you believe the charge is incorrect. Depending on the circumstances, federal or state consumer protections may also apply.

What if my health plan denied a claim or says a service isn't covered?

Find out why. A claim may be denied for different reasons, and the next step depends on what happened. Review your EOB/MHS or other notice for the reason, then ask what review or appeal options are available. Keep copies of your EOB/MHS, provider bills and communications about the claim.

What if I can't afford the bill, even if it's correct?

Don't ignore it. Contact the provider's billing department and ask what options may be available. Depending on the provider and your circumstances, possibilities may include a payment arrangement or other financial-assistance options. If the amount is related to how your insurance processed the claim, contact your health plan as well so you understand exactly what you're responsible for before making arrangements.

How can I reduce the chances of getting another unexpected bill?

You can't predict every healthcare expense, but for planned care you can confirm that the provider and facility are in your network; ask whether other providers involved in your care are also in network; check whether the service needs prior authorization; ask for an estimate of what you may owe; understand your deductible and out-of-pocket maximum; and compare your EOB/MHS with bills you receive.

The goal isn't to become an insurance expert. It's to know enough to recognize when something doesn't look right - and know where to go for help.

So how do you choose? Start with four practical questions.

So how do you choose? Start with four practical questions.

1. What can I comfortably afford each month?

Don't start with a premium that strains your budget.

2. How much healthcare am I likely to use?

Think about doctors, specialists, prescriptions and anything you reasonably expect during the coming year.

3. How much financial risk am I comfortable taking on?

Look at the deductible, cost sharing and out-of-pocket maximum - not just the premium. Ask yourself what would happen to your budget if you had an unexpected illness, injury or hospital stay.

4. Am I getting all the financial help available to me?

Check before deciding what is - and isn't - affordable. Then compare your options based on what you're paying, what you're getting and how well the combination fits your life.

woman reviewing her health insurance benefits on her mobile phone
couple reviewing their health plan

Affordable doesn't have to mean "cheapest."

Affordable doesn't have to mean "cheapest."

That's probably the most important thing to remember. Health insurance is there for the routine things you can anticipate - and the things you can't. 

Finding affordable coverage means finding a balance you can live with:

  • A monthly payment you can manage.
  • Costs you understand.
  • Coverage that meets your needs.
  • And financial protection if something unexpected happens.

That's a much more useful way to think about affordable.

Still have questions?

Still have questions?

Not necessarily. A lower-premium plan may have a higher deductible or higher costs when you receive care. Think about total expected cost, not just the monthly payment. 

Your premium is the regular amount you pay to keep coverage. Your deductible is the amount you may need to pay toward certain covered services before your plan begins sharing those costs. 

Look at more than price. Consider your expected healthcare needs, doctors and hospitals, prescriptions, benefits, provider network and total costs. 

Yes. Your plan's network can affect what you pay, and some plan types generally require in-network care for coverage except in certain circumstances. Check whether your preferred providers and pharmacies participate before choosing a plan. 

You may qualify for financial assistance depending on your circumstances. Because eligibility rules and amounts can change, check current information when you're shopping rather than relying on an old threshold.

An Explanation of Benefits (EOB) or Member Health Statement (MHS) shows how your health plan processed a claim, including what was submitted, what the plan paid and what you may owe. Comparing your EOB/MHS with a provider bill is an important first step when a medical charge surprises you.

Compare the bill with your EOB/MHS, look for charges you don't recognize or amounts that don't match, and contact the provider and your health plan if something doesn't make sense.

Depending on the reason for the denial and your plan, review or appeal options may be available. Review the notice you received and contact Florida Blue to understand the process that applies to your situation.

Contact the provider rather than ignoring the bill. Ask about available payment arrangements or financial-assistance options. If you're unsure whether the amount is actually your responsibility, talk with your health plan first so you understand how the claim was processed.

Individual and family Marketplace coverage generally has an annual Open Enrollment Period. Certain life events may qualify you for a Special Enrollment Period outside that window.

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