A Guide to Choosing the Right Health Insurance Plan for You
Learn how to compare health insurance based on eligibility, total yearly cost, doctors, hospitals, prescriptions, deductibles, out-of-pocket limits, and PPO, HMO, EPO, or POS network rules.
Which Health Coverage Options Are Available to You?
Before choosing the right health insurance plan, identify the coverage sources you can actually use. Marketplace, employer, COBRA, Medicaid, CHIP, and Medicare all have different eligibility and enrollment rules.
ACA Marketplace
For many individuals and families without affordable job-based coverage, the Health Insurance Marketplace is an important starting point. Marketplace plans can qualify for Premium Tax Credits when the household meets the applicable rules.
Employer Coverage & COBRA
Compare the employer contribution, network, deductible, and benefits. If you recently lost job-based coverage, review COBRA continuation rights and Marketplace Special Enrollment options.
Medicaid & CHIP
Households with limited income should check Medicaid and CHIP. Applications are available year-round, although eligibility rules vary by state and program.
HMO vs. PPO vs. EPO vs. POS
Network type affects which doctors and hospitals you can use, whether referrals are required, and whether non-emergency out-of-network care is covered.
HMO
Generally emphasizes in-network care except emergencies. PCP and referral rules can vary by plan.
PPO
Generally lets you use out-of-network providers at additional cost and usually does not require specialist referrals.
EPO
Generally covers routine care only when you use the plan network, except emergency care.
POS
You generally pay less in-network, and POS plans require a primary-care referral to see a specialist.
How to Choose the Right Health Insurance Plan
Use the same checklist for every plan so you’re comparing equivalent information rather than marketing headlines.
Compare your monthly premium
For Marketplace plans, compare the premium after any Premium Tax Credit you qualify to receive. For 2026, the IRS says PTC income eligibility generally runs from 100% through 400% of the applicable federal poverty line, subject to the other eligibility rules. Review current IRS PTC guidance.
Understand the deductible
A deductible applies to certain covered services before the plan begins paying for those services. Some benefits may be covered before the deductible, so read the plan rather than assuming everything is 100% your responsibility first.
Check copays and coinsurance
Compare primary care, specialist, urgent care, emergency care, hospital, lab, imaging, therapy, and prescription cost sharing.
Review the out-of-pocket maximum
This limits qualifying spending on covered in-network benefits during the plan year. Premiums, non-covered services, and some out-of-network costs do not count toward the Marketplace limit.
Verify your doctors and hospitals
Use the provider directory for the exact plan and plan year. Do not assume that a doctor who accepts the insurer participates in every plan offered by that company.
Check your prescriptions
Review the plan’s drug formulary, tier, copay or coinsurance, prior authorization, step therapy, quantity limits, and preferred pharmacy rules.
Estimate total yearly cost
HealthCare.gov recommends comparing estimated total yearly costs, not premium alone. Consider annual premiums plus the out-of-pocket costs you realistically expect. See HealthCare.gov’s total-cost guidance.
Read the Summary of Benefits and Coverage
The Summary of Benefits and Coverage (SBC) provides standardized information that helps compare deductibles, benefits, exclusions, and common coverage examples.
Make Sure You Can Enroll Before You Choose a Plan
HealthCare.gov’s annual Marketplace Open Enrollment period runs from November 1 through January 15. Outside that window, you may still qualify for a Special Enrollment Period because of certain life events or other qualifying circumstances.
Open Enrollment
Use HealthCare.gov’s current enrollment guidance to verify dates and deadlines.
Special Enrollment
Losing coverage, marriage, birth, adoption, moving in some circumstances, and other qualifying events can create a Special Enrollment opportunity.
Medicaid & CHIP
Applications for Medicaid and CHIP are available throughout the year. Eligibility rules vary by state and household circumstances.
Choosing a Health Insurance Plan FAQs
What should I look at first when choosing health insurance?
Start with eligibility and the coverage sources available to you. Then compare doctors, hospitals, prescriptions, premium, deductible, cost sharing, out-of-pocket maximum, and network structure.
Should I choose the health plan with the lowest premium?
Not automatically. A lower premium can be paired with different deductibles, networks, or cost sharing. HealthCare.gov recommends comparing estimated total yearly costs, not premium alone.
Is a PPO better than an HMO?
Not necessarily. PPOs generally offer more out-of-network flexibility, while HMOs generally emphasize in-network care. The better choice depends on the exact doctors, hospitals, benefits, and costs in the plans available to you.
How do I know whether my prescriptions are covered?
Check the plan’s current formulary for each medication and review its tier, cost sharing, prior authorization, step therapy, quantity limits, and pharmacy network.
Can I choose a Marketplace plan outside Open Enrollment?
You may be able to if you qualify for a Special Enrollment Period. Medicaid and CHIP applications are available year-round.
Ready to Compare Health Insurance Options?
Use this checklist to evaluate the plans available in your area, then request health insurance quote information when you’re ready to compare current coverage.
Disclaimer: Advocate Health Plans provides educational information only and does not provide professional insurance, legal, tax, or financial advice. Verify current plan details and eligibility before enrolling.