When evaluating Individual & Family health insurance options, there’s no lack of information available. In fact, it might seem like drinking from a firehose. While you can and should get familiar with all the details of any plan you’re considering, here are some suggestions to help you prioritize your needs and choose the best options for your needs as efficiently as possible.

Start with your family’s health needs

Picking a plan starts with understanding your family's health needs. If it's just you, the choice might be straightforward. But if you have a spouse and kids, their needs can vary, especially if someone has a chronic condition or requires regular care. Start by jotting down:

• Names of your family doctors and any specialists you visit
• Prescription drugs and their dosages for each family member
• Your preferred hospitals, pharmacies, and labs
• How often each family member sees a doctor

It's good to remember that, thanks to the Affordable Care Act (ACA), pre-existing conditions no longer affect your insurance costs or care. Premiums are based on factors like age and location, but not medical history.

Know what’s covered

Every ACA-accredited plan covers 10 essential benefits, making it easier for you to compare plans. These essential benefits include:

 

Some plans might also offer additional perks like:

• Adult dental and vision care
• Birth control and breastfeeding support
• Chronic disease management for conditions like diabetes

If adult dental and vision aren’t included in your chosen plan, you can usually find these as separate policies.

Also, keep in mind that while the essential benefits are standardized, the costs are not. For example, while every plan covers doctor visits, the cost you’d pay for the visit will vary from plan to plan.

Good to know: The federal government offers premium tax credits to individuals and families to help lower the cost of health insurance premiums. The amount of the credit depends on your income and family size, and it's designed to make purchasing health insurance more affordable for those who qualify. You can calculate your federal subsidy when you’re shopping for plans through Alight.

Understand the Summary of Benefits and Coverage (SBC)¹

To help you compare options, you can see a detailed Summary of Benefits and Coverage (SBC) for each plan. This important document contains a wealth of useful facts, figures, and scenarios you can use to prioritize your choices. The SBC for each plan gives you:

• Answers to the most important questions about the plan, costs, limits, and key terms. Information on how each plan is structured (i.e., as an HMO, PPO, or other design type; these are described in Understanding Plan Types).
• A clear explanation of why each aspect of coverage is important
• Examples of how the plan covers different medical situations
• A list of services the plan doesn’t cover
• Options to read the SBC in a variety of alternative languages, such as Spanish, Tagalog, Chinese, and Navajo
• Real-world examples, showing how the plan would support you in a few actual scenarios
• Clickable, plain-language definitions for all technical and industry terms that may be unfamiliar to you²

Drilling down with specific doctors and prescription drugs

Even with all this information, it’s still possible to select a plan that doesn’t quite fit all your needs—one that, for example, doesn’t cover all the doctors or drugs you depend on. While this may not be a deal-breaker, it’s a good idea to check both issues as they relate to you and your family. Here’s what to check for:

• Provider network: Check to be sure that the plan’s network includes doctors, hospitals, and other facilities you use on a regular basis. Ideally, most or all your existing providers will be in-network for a plan you’re considering. If not, you can compare the cost of seeing an out-of-network provider against finding a new provider that does participate in the network.
• Drug formulary: While all plans must cover prescription drugs, no plan covers them all equally. So check the plan’s formulary, or drug list, to be sure the drugs your family uses are covered. Then, to estimate your cost, look further to see which of the five “tiers” each drug is in. Drugs in tiers 1 and 2 are typically least expensive; drugs in tiers 3 through 5 usually cost more.

Choosing an Individual & Family health insurance plan requires careful consideration of your health care needs and financial situation. By understanding the 10 essential benefits and evaluating all the offerings, you can select a plan that not only meets your minimum requirements but also offers the additional coverage that suits your lifestyle and health circumstances. Always take the time to compare different plans and insurers to find the best fit for your health care needs and budget.

Still need guidance?

Contact Alight Retiree Health Solutions for help understanding and navigating your choices. Our licensed Benefits Advisors offer personalized, unbiased guidance so you can make informed decisions about your health care.

¹Summary of Benefits and Coverage Completed Example
² Health Insurance Rights & Protections