5 Things You Must Know Before Choosing Health Insurance

Buying health insurance can be confusing. Most people either overpay for coverage they don’t need or pick a plan that leaves them exposed.

After working with thousands of families and individuals through eHealth20, I’ve seen the same mistakes over and over. If you want to avoid surprise bills, wasted money, and frustration, here are the five things you need to understand.

Let’s break them down:

1. Deductible: The First Cost You Pay

Your deductible is the amount you pay out of pocket before insurance starts covering anything.

If your deductible is $3,000, you’ll need to pay $3,000 in medical costs before your insurance company contributes.

Plans with low premiums usually have high deductibles. And many people focus on the monthly price without realizing how much they’ll actually pay when something happens.

Real example: One client had a $9,000 deductible and didn’t realize a broken wrist would be completely out-of-pocket. He thought his $320/month plan “covered everything.”

Deductibles can vary greatly – I’ve seen them as low as $500 annually or as high as $12,000 annually, and sometimes even more, depending on the specific plan.

2. Co-insurance: Sharing the Bill After the Deductible

Once you meet your deductible, you’ll still split costs with the insurance company. That’s called co-insurance.

A common plan might cover 80%, while you’re responsible for 20%. So if you have a $1,000 hospital bill after hitting your deductible, you still pay $200.

This is where most people get surprised. They think insurance pays 100% after the deductible, but that’s rarely true. Co-insurance directly affects your expenses for medical care after you’ve met that initial deductible.

For example, if your plan has 20% co-insurance – a common figure – it means you’ll pay 20% of the approved medical bill, and your insurer will cover the remaining 80%. So, if your deductible was $500 and you then have a covered medical service costing $100, you’d pay $20 (20% of $100), and the insurance company would pay $80.

3. Co-pays: Flat Fees That Seem Simple But Add Up

Co-pays are fixed fees you pay when you see a doctor or fill a prescription.

$25 to see a doctor.
$10 for generic meds.
$75 for an ER visit.

These don’t count toward your deductible in most plans. That’s the part most people miss.

So even if you pay co-pays all year long, they usually don’t reduce the $5,000 or $8,000 deductible you’re working toward.

4. Out-of-Pocket Maximum: The Cap That Matters Most

This is the real financial safety net in your plan. The out-of-pocket max is the highest amount you’ll pay in a year for covered services, including deductible, co-insurance, and co-pays.

Once you hit this number, insurance covers 100%.

Example: If your out-of-pocket max is $7,500, that’s your financial worst-case scenario for the year. Anything beyond that? Covered.

Everyone should know this number. If you’re facing a surgery or cancer diagnosis, this is the number that matters.

For instance, if your out-of-pocket maximum is $2,000 annually, once your payments for deductibles, co-insurance, and co-pays hit that $2,000 mark, you generally won’t be liable for further charges on eligible, in-network medical services for that year.

5. Provider Network: Where You Can Actually Use Your Insurance

Insurance doesn’t work everywhere. That’s why networks are a big deal.

You’ll get better prices and fewer surprises if you stay in-network. Go out-of-network, and you could be stuck with a $5,000 bill that insurance refuses to pay.

Plans like HMOs often won’t cover anything outside the network—unless it’s a true emergency.

Choosing the right health insurance plan in the United States doesn’t need to be an overwhelming ordeal. By understanding these key factors, you’re already in a much stronger position to make an informed decision.

The One Thing That’s Always True

Most complaints about health insurance come down to one thing: not understanding how the plan works before something happens.

I’ve seen it too often. People panic when they get a bill, call their insurance, and realize they misunderstood the fine print.

Don’t wait until you’re sitting in the ER to read your policy.

Real-World Support: A Client Story

Tony Spanferd came to us five years ago after his third child was born. He needed a plan that covered his growing family but didn’t crush him financially.

We helped him find a plan with a balanced deductible and solid provider network. Since then, we’ve answered every question he’s had—whether it was about a confusing claim, changing income, or a new specialist.

He said the biggest difference working with us is real-time answers, not automated hotlines or vague answers.

What You Can Do Now

If you already have insurance, pull up your plan and check these 5 things:

• What’s your deductible?
• What’s your co-insurance rate?
• Do you know your co-pays?
• What’s your out-of-pocket max?
• Is your doctor in-network?

If you don’t know, that’s a problem.

And if you’re shopping for a plan, don’t just look at the monthly cost. Use this list to guide your decision.

We’re not just here to sell you a plan. Our job is to make sure you understand what you’re buying—and to keep helping you even after you’ve signed up.

Want help reviewing your current plan or comparing options? Reach out at eHealth20. We’ll give you direct answers—no fluff.