How to Get the Most Out of Your Health Insurance Plan
Health insurance may be costly, but it’s worth your while if you can maximize it.
Since the onset of the global pandemic, healthcare has never been more critical. However, the cost involved also continues to rise. In 2020, health spending reached $4.1 trillion — a 4.3% increase from 2019. Over half (53.6%) were on hospital care, doctors’ services and prescription drug purchases.
These figures highlight the value of health insurance. However, another challenge surfaces — health plan premiums have also increased. 9.6% of Americans were uninsured as of mid-2021, and the primary cause is cost.
While health coverage isn’t cheap, its benefits outweigh the drawbacks. You can apply strategies to make the most out of it, like staying within your plan’s network and taking advantage of screenings and assessments.
MoneyGeek’s guide explores this in more detail and provides tips to help you choose the right plan and maximize its benefits.
Decide on the Right Health Plan
It's best to explore your options before enrolling in a health insurance plan — even if you like your current one. Remember, several types are available, so it's crucial to find one that fits your needs. Each plan may have varying benefits and costs.
Understanding the different elements of an insurance plan and seeing how it aligns with your healthcare needs can lead you to your best option.
Elements of an Insurance Policy
Reviewing your health insurance policy is wise — even if you're only renewing it. You never know whether rates or benefits have changed, so don't assume it's identical to your previous one.
Cost, although an essential factor, shouldn't be your only one. Others to consider are a provider's reputation or a plan's network. Our table below provides a comprehensive list that you can use to evaluate your options.
- What to ConsiderWhat It SignifiesHow to Choose
You can continue to access the
benefits indicated in your health
insurance plan by paying a
premium. You may pay it
monthly, quarterly, semi-annually
Health plan premiums vary depending
on several factors. While there’s no
ideal amount for a premium, it must be
affordable throughout the year.
Remember, although it’s the primary
expense connected to health
insurance, you still need to consider
Each year, you must spend a
specific amount out-of-pocket
before your health insurance
provider begins covering your
health care costs. It’s known as
A health plan with a low deductible is
usually best if you know you need a lot
of medical care. Reaching it sooner
means your provider starts sharing in
your costs earlier. However, a high
deductible plan may be better if you’re
in good health because it lowers your
A copay is one way of
cost-sharing between you and
your health plan provider. It
involves paying a fixed amount
for each service you avail of
before receiving it.
Your copay varies depending on the
service you need, but it usually costs
$10 or more.
A copay may be better than
coinsurance, especially if your health
services are expensive. Regardless of
the total cost, you will always spend
the same amount, making your health
Your provider is the insurance
company issuing your health
plan. Your options may vary
depending on where you live. It is
also the entity that will process
the claims you file.
The cheapest health insurance
provider may not necessarily be the
best option. Consider other factors like
service quality, plan availability and
complaints about their claims process.
It's also best to find a financially stable
provider to ensure they can pay their
Your network refers to the group
of medical professionals or
entities that provide services
covered by your health plan.
Typically, your provider won't
cover costs from out-of-network
Consider your preferred doctors,
clinics or labs and see whether they're
part of your plan's network. Ideally,
they should be. If not, you may have to
decide whether you'll prioritize your
preferences or costs.
Comparing Health Insurance Plans
Besides the various elements of a health insurance plan, you must also consider its type. Your choice often impacts factors like your premium and network. Knowing the differences between them can come in handy when comparing options.
Choosing the right health plan for you is essential. The table details the pros and cons of each allowing you to make the best possible decision.
- Health Insurance PlanWho This Plan is Best ForBenefitsPotential Drawbacks
A PPO plan works
best for members
who value flexibility
over cost. Although
you may pay higher
have access to a
Your plan's coverage
may extend to providers
not part of your network.
Since a PPO doesn't
require a PCP, you don't
need to have a referral
to see a specialist.
The additional flexibility
you get doesn't come
for free. Compared to
HMP plans, PPOs have
These also usually
increases what you pay
out of pocket.
Members who keep
an eye on their
budget but aren't
looking for flexibility
will appreciate an
HMO plan. It'll work
for you if you can be
within your plan's
An HMO is a
plan because it typically
has lower premiums.
Some HMOs don’t have
deductibles, so your
provider begins sharing
your costs immediately.
You’ll also have a
primary care provider
who manages your
Your plan's coverage is
strictly limited to
providers within its
network. If your doctor
isn't part of it, you'll
have to choose a
different primary care
provider. It's crucial to
stay within your
network because your
plan won't cover costs
providers unless during
An EPO plan is an
excellent option for
members who don't
need much flexibility
for medical service
providers but don't
want the hassle of
getting a referral
before visiting a
With an EPO plan, a
primary care provider
doesn't need to
coordinate your medical
requirements. It means
that you have the
freedom to go straight to
EPO plans have
They're slightly pricier
than HMOs but are
more affordable than
Although you can go
directly to a specialist
without a referral, he
must be within your
network to ensure it's
you'll have to spend
out-of-pocket for it.
Premiums aren't as
expensive as PPOs,
but HMO plans are still
Members who don't
mind keeping track
of a more complex
benefit structure can
benefit from a POS
plan. It offers
affordable than a
A POS officers several
benefits similar to PPOs
but with more affordable
premiums. You can use
providers in and out of
your plan's network.
have no deductibles and
low copays, lowering
your healthcare costs.
POS plans may be
cheaper than PPOs,
but you'll still get lower
rates with an HMO.
You have a deductible
services and higher
copays, which may
increase your medical
costs. You also need a
PCP to refer you to a
Members in good
health who don't
need much medical
attention are ideal
candidates for an
HSA. You can have
coverage and save
You can contribute as
much as $3,650 in 2022
for self-only coverage
and $7,300 for family
coverage. Your savings
earn tax-free dollars,
which you can use to
pay for your deductible,
copay and prescription
An HSA is only
possible if you have a
High Deductible Health
Plan. Your deductible
must be at least $1,400
for individual coverage
or $2,800 for family
coverage. You may
out-of-pocket if you
need constant medical
Smart Tips: Choosing the Best Plan For Your Needs
Choosing the right health plan can be stressful. It's not a matter of selecting the most affordable one but something that can give you appropriate coverage.
You won't be able to maximize your plan's benefits if it doesn't fit your needs. Or, you may be paying for coverage you won't use. Either way, it will make it seem like your health coverage isn't worthwhile.
Here are some tips to help you choose the best health insurance plan.
Make a thorough assessment of your medical needs
A clear understanding of how much medical care you need is a good place to start. Those who have extensive healthcare needs may be better off with plans with a low deductible. However, a high deductible health plan with a low premium may be more cost-effective for members in good health.
Be realistic about your budget
Although cost isn't the only factor to consider, it plays a significant role in your decision. Remember, the premium isn't the sole expense connected to health insurance. You also need to factor in deductibles, out-of-pocket maxes, copays and coinsurance. However, you'll lose coverage if you can't cover your monthly due.
Know what health plans are available to you (and where to get them)
It's best to know what type of plans are available to you. For example, depending on your age or income, you may qualify for Medicare or Medicaid. You can also get healthcare coverage through your employer or the Marketplace.
Brush up on health insurance terms
What makes health insurance complex is that many terms may be unfamiliar. Understanding what a deductible is and how it's different from copay and coinsurance can be a great help when you start comparing plans.
Consider your preferences
Be clear about your preferences regarding doctors, hospitals, labs or clinics. Don't assume that your physician is part of your plan's network — ask your doctor if you have to, but it's better to know before you enroll. If you're not particular, it may make HMO plans more attractive.
Compare health plans across providers
Exhaust all your options before deciding. Health insurance companies may price plans differently, even if they have the same coverage. Comparing them helps you find the best possible deal.
Determining the Right Amount to Spend on Health Insurance
Health coverage is expensive. MoneyGeek's analysis found that the average cost of health insurance for a 40-year-old is $477 per month. That comes up to almost $7,000 a year.
However, how much you spend varies based on your unique profile, so what's appropriate differs for each person. Our guide provides some tips to help you determine if you're paying too much for health coverage.
Follow the 10% rule
How much you earn in a year can be a sound basis for how much you should spend on coverage. Typically, it should be 10% of your income. For example, if you earn $67,521 per year, the median household income for 2020, then $6,752.10 should go to health insurance.
Determine what you used and what you didn't
At the end of a coverage period, review the summary of benefits and coverage, whether or not you intend to renew your plan. See if there are additional benefits you aren't using. Taking them off can help you save on premiums and ensure you aren't overpaying for coverage.
Don’t decide based on technical terms
Don't get swayed by terms like "Catastrophic" or "Platinum" health plans. You may not like the sound of the former, but if you qualify, it might be your most cost-effective option. Don't go with the latter just because it sounds better.
Consider where you live
The average cost of health insurance varies between states. For example, policyholders in Colorado spend an average of $4,052, while those in West Virginia pay around $8,546 a year. However, other factors like age or metal tier may affect your premium.
Expert Tips on Maximizing Health Insurance Benefits for Healthcare Costs
Health insurance can be pricey even if you’re taking steps to not overspend on coverage. Remember, your health plan can impact your finances significantly, so it's crucial to maximize it. Besides helping pay for medical expenses, you can take advantage of lesser-known benefits. Our guide explores these further, along with some mistakes to avoid. These can help you make the most of your health plan.
Don’t automatically accept a denied claim
Sometimes, your health insurance provider denies a claim you file. When this happens, don't give up immediately. You can appeal this through its internal process or an external review. Either way, it's best to exhaust all means — it could result in an overturned decision and the processing of your claim.
Keeping within your network
A common mistake policyholders make is using services outside their plan's network. You'll have to pay for these services if you have an HMO or an EPO plan. It won't count towards your deductible, so you're no closer to getting our provider to share your medical costs.
Don’t forget about benefits and discounts
Some health insurance plans include wellness programs. These benefits focus on stress management, nicotine cessation or weight management. You may find that you have discounts on gym memberships — these can go as much as 50%. Others allow you to get LASIK surgery at a lower rate.
Determine the right deductible
A high deductible isn't necessarily bad; a low one isn't always good. Remember, the best limit depends on your medical needs. Members who require a lot of medical attention can benefit from a low deductible — since they'll reach it sooner, their provider begins sharing costs earlier. A low deductible plan is best for someone who doesn't frequent the doctor and can take advantage of the low premium.
Take advantage of tax benefits
You can apply your health insurance premiums as tax deductibles. However, it only applies if you enrolled through the Marketplace and are paying it through your pocket (as opposed to an employer-sponsored health plan).
Navigating Health Insurance on Case-By-Case Scenarios
People tend to associate health insurance benefits with unexpected medical expenses. However, it can provide financial support in non-emergent cases.
Your health plan can come in handy in different scenarios, allowing you to manage your finances better. There are several potentially expensive situations where knowing how to maximize your health insurance can make them more manageable.
Having a New Child
A child is a blessing, but you can't deny that soon-to-be parents must consider the expenses. The International Forum for Wellbeing in Pregnancy found that most women get stressed during pregnancy because of financial challenges. Although health insurance isn't the answer to all these costs, it can alleviate money worries and keep expectant mothers healthy.
Preparing for and having a newborn involves a lot of medical attention for mother and child. Here's how you can maximize your health coverage.
- Use it for prenatal visits: Prenatal visits are essential because it's best to catch and manage any condition before it puts your pregnancy at risk. Your plan can cover the costs of these visits without a copay. You also don't need to go through your PCP for a referral to see an OB/GYN, nurse practitioner or midwife.
- See if you're eligible for Medicaid or CHIP: If you don't have health coverage when you find out you are pregnant, see if you qualify for Medicaid or CHIP. Unlike Marketplace plans, you don't have to wait for the Open Enrollment period to get health insurance. These can give you access to free or low-cost coverage.
- Determine if you qualify for special enrollment: If you don't qualify for Medicaid or CHIP, see if you do for a Special Enrollment Period. These require you to be undergoing a significant life event. Being pregnant will not qualify you, but giving birth does.
- Report your child's birth to the Marketplace: After giving birth, update your application as soon as possible. It may change your coverage options, resulting in lower monthly premiums. You can either add your baby to your current plan or enroll in a separate one for the remainder of the year. Remember, your baby's first year includes a lot of visits to a pediatrician.
- Get breastfeeding help: A Marketplace health plan can also cover consultations with a lactation consultant. It also includes equipment, such as breastfeeding pumps. The best part of this is you don't have to spend on copay.
Not all surgeries happen during emergencies or after accidents. Some procedures are non-emergent, giving you more freedom to decide when you want to undergo them.
However, remember that surgeries can be expensive regardless of when you decide to go under the knife. Although costs vary depending on the complexity of your procedure, it can still consume a chunk of your savings.
A surgery always entails expenses but having health insurance can help minimize costs. Here are some practical ways to maximize your health plan benefits for planned procedures.
- Ensure your coverage: See if your health plan covers the procedure you want. Health insurance typically shoulders part of your surgery (or sometimes, the entire thing) as long as it's medically necessary. For example, your provider may cover elective cosmetic surgery like breast reduction if it helps alleviate back pain.
- Use pre-authorization: If your plan doesn't cover the procedure you want, check if it requires pre-authorization. If yes, your doctor must inform your health insurance company that the surgery is medically required before you have it. If your healthcare provider doesn't do it, prepare to foot the entire bill.
- Ask about discounts: More complicated procedures will typically cost more than simple ones. However, the costs can quickly increase because these involve surgical teams. Ensure that most, if not all, of your medical service providers are in-network. Even if your health plan covers the procedure, you'll still pay for out-of-network services.
- Time your procedure properly: Check your deductible to determine where you’re at in reaching it. Timing can considerably impact your expenses. See if you can schedule it when you hit your deductible (or are just about to). Once you've paid up to your deductible, your health insurance provider will share the remaining costs.
Surgeries, injuries or accidents can have long-lasting effects, and some people lose mobility. A physical therapist can help you get you back in shape, but their services don't come cheap.
OrthoBethesda puts a single session to cost anywhere between $75 to $350. Imagine if you're on the higher end of that spectrum and need ten sessions. Health insurance can considerably reduce costs, but you still need to consider some things.
Health insurance is an excellent way of reducing possible physical therapy costs. However, before pushing through with your treatment, ask the following questions to ensure you’ve covered all your bases.
- What limits are in place? There are several limits to check with your health plan. Some only cover PT within the first three months. Others only pay for the service for a specific number of sessions. If the recommended duration of physical therapy exceeds your plan's limit, you know you'll need to pay at some point. Discuss your options with your physical therapist if you know that'll be challenging.
- Can you use out-of-network therapists? Your health plan type determines your flexibility regarding medical service providers. If you have an HMO or a PPO, you can only stay in-network if you want therapy covered. Plans that allow you to go with out-of-network therapists may have higher copays or coinsurance, so if your preferred therapist isn't within your network, you might want to calculate the difference in cost.
- Do you need a referral? Some health insurance plans require your primary care provider to issue a referral before covering a service. If you're unsure whether you need one, check with your provider. Getting a referral isn't complicated — simply tell your PCP you need one — but it's still an extra step. However, skipping it may cost you more money than it's worth.
- Is equipment covered? With physical therapy, your therapist may ask you to do some exercises while you're at home. Some of these are simple and are a matter of completing specific movements. However, others require equipment — these may range from resistance bands to Total Resistance Exercise (TRX) systems. Sometimes, even if your health insurance plan covers the actual session, it may draw the line at equipment. It's best to confirm it before purchasing home equipment.
When you've been diagnosed with heart disease, cancer or diabetes, you'll always have it. In the U.S., six out of every ten adults suffer from a chronic illness.
Chronic diseases cause physical, mental and financial stress. A person suffering from a chronic illness spends an average of $6,032 in direct health care. That's around five times higher than someone without it. Fortunately, knowing how to maximize your health insurance plan can help you manage costs.
Frequent doctor visits and regular medication can quickly dent your savings. Having health coverage doesn't mean you won't have to spend anything anymore, but it can help you reduce some costs. Here are some strategies you can apply.
- Take advantage of preventive care services: Check out your health plan’s wellness benefits. You can get discounts on gym memberships, have access to a weight loss counselor or join a cooking class. These may not reduce your direct costs, but you can use them to improve your overall health. That may eventually lead to a change in your medication or lessen the frequency of your doctors' visits.
- Choose a low deductible plan: You typically need more medical attention when dealing with a chronic illness. It translates to numerous doctor appointments, regular tests and medication — all of which cost money. A low-deductible health plan is a better option. Staying in-network (if required) ensures you'll reach your limit early. After that, your coverage kicks in, and your provider begins sharing in costs. It can reduce your medical expenses considerably.
- Maximize self-management programs: Living with a chronic disease can elicit feelings of hopelessness. Some programs focus on letting you build confidence in managing your condition. Believing that you can lead an active lifestyle helps patients' mental, emotional and physical well-being. You can also pick up techniques to nurture relationships with family and friends despite your condition.
- Consider maintenance medication: Most people with chronic illnesses also have prescribed maintenance medication as part of their healthcare regimen. Most health plans provide prescription drug coverage but don't cover all medicines. Consider it when you're choosing a health insurance plan. Pick a plan that covers your medication because it can help reduce expenses.
Mental Health Treatment
Present healthcare needs aren't limited to physical injury. Now mental well-being is as important, especially in the wake of the COVID-19 pandemic. The U.S. spent $225 billion on mental health treatment and services in 2019 alone.
But, like all treatments, these aren't free. The need for counseling or group therapy may impact your finances. Having health insurance is one way to cushion the blow.
Although mental healthcare services are included in the 10 essential benefits of all plans in the Marketplace, keep the following things in mind to ensure you maximize your coverage.
- Confirm that the service is covered: Mental health treatment isn't limited to one-on-one therapy sessions with a psychologist or psychiatrist. It includes group therapy, addiction treatment, telemedicine and online therapy and psychiatric emergency services. Knowing these allows you to understand better what your plan can cover.
- Ensure you have a diagnosis: You may want to schedule sessions with a therapist for many reasons. You could have had a death in the family and are experiencing difficulty coping. Or you might be looking for ways to get out of a toxic relationship. Although all these are valid reasons, most health plan providers require services to be medically necessary before covering them. So it's best to have a formal diagnosis.
- Clarify the limits of your coverage: Determine what limits your plan set for mental health treatments. These could include having to stay in-network, requiring a referral or only covering a specific number of visits to your therapist. This way, you'll know what your plan covers and get an idea of how much you'll need to prepare for costs that you'll shoulder.
- Consider an HSA plan: Younger generations (especially Millennials) are more receptive to going to therapy than older generations. If you're one of them and your preferred therapist isn't in your plan's network, consider getting an HSA plan. You may have a high deductible, but you'll benefit from the low premium. You can also use your savings to pay for out-of-network service providers.
How to Take Advantage of Hidden Benefits
Having a health insurance plan is an excellent way to reduce medical costs. When your expenses become more manageable, you feel you're maximizing your coverage.
That's true, but lower healthcare costs are only part of maximizing your health insurance. Ensuring your take advantage of available benefits is another — and it applies to those that policyholders may frequently overlook.
MoneyGeek highlights four that you can explore further.
Having a case manager
Having one central person handle your healthcare matters can make life much easier. It's especially true if you have a chronic illness. They can answer all your questions and align with your healthcare providers so everyone's on the same page.
Rushing to the hospital isn’t always the answer for unknown aches, pains and sickness. You can use the nurse line, which is 24/7, to get more information. They may save you from a trip to the doctor by providing the help you need.
Getting the medical care you need without setting foot in the hospital is a source of relief. It saves you time, effort and money. Telehealth has gained traction and has become a popular healthcare channel. Best of all, you can get it at a discounted rate — sometimes, it's free!
Health plans that have wellness programs offer discounted membership rates for fitness clubs. Being physical and working out can save you money in the long term because it improves your health. You may need less medical attention in the future.
Health Insurance Benefits FAQs
Although consumers are encouraged to enroll in health insurance plans, several aspects may remain unclear. MoneyGeek included questions policyholders typically ask to provide additional information.
Expert Insight on Maximizing Your Health Insurance
Healthcare and health insurance are expensive. That’s why it’s good to know you’re making the most of it. MoneyGeek reached out to several industry experts for their insights on maximizing your health insurance.
- What’s the best way for buyers to determine the best insurance plan for their needs? What should they look for first?
- What’s the danger of enrolling in a health plan that isn’t right for you?
- Health insurance costs have been increasing. What advice can you give policyholders so they can maximize their coverage?
- Besides the usual advantage of having health insurance (helping you with medically covered medical expenses), are there other benefits that policyholders may not be aware of? How can they make the most out of these?
Founder & CEO of Seniors Life Insurance Finder
Insurance Specialist at Facet Wealth
Spokesperson and Public Relations Consultant for UCare
Resources for Maximizing Your Health Insurance
Explore other ways to use your benefits to get the most out of your health plan coverage. Review the following calculators, mobile apps and possible support groups to help you find what works best for your situation.
- First-year baby costs calculator: Having a newborn baby may be expensive. You can use this calculator to estimate your costs. You can also determine which expenses your plan can cover.
- Household health spending calculator: Discover your estimated healthcare needs based on several factors. Remember, besides your premium, you should consider out-of-max limits and taxes.
- Health insurance Marketplace calculator: Use this calculator to estimate how much you’ll spend for a Silver plan from the Marketplace. You can also see whether or not you’re qualified for financial assistance.
- NAMI support groups: Whether you have a mental health condition or are a family member of someone who has one, having a support group can help you cope. See if you can find one that fits your needs.
- Mental Health America: Find a support group that matches what you’re looking for, whether it’s for mental health or substance abuse.
- Chronic Disease Coalition: There are more people with chronic illnesses than we think. If you’re one of them, the CDC can help you understand your rights as a patient.
- Hand-to-Hold: It provides support, specifically for parents who need to put their newborn in NICU. You can join a group to share experiences or meet separately with a family support specialist.
- Sutter Health Pregnancy and Parenting Support Groups: Having a baby is a joyous event but can be overwhelming. Whether you need to talk about newborn care or postpartum wellness, Sutter Health can provide the support you need.
- The Mother Baby Center: Every mother has a preferred birth experience. The Mother Baby Center helps mothers and newborns get the care they require (and deserve).
- MySugr: This app allows people with diabetes to track their data and view a progress report. You can also participate in their challenges to ensure you keep your condition under control.
- One Drop: A one-stop-shop up to help you manage your condition. Those with diabetes, high blood pressure, heart conditions or weight challenges may find it helpful.
- Pregnancy+: This app acts as an organizer and information resource simultaneously. You can calendar your doctor’s appointments, use various pregnancy tools and read pregnancy guides.
- What To Expect: Whether you’re trying to conceive or already on your way to giving birth, this mobile app has something for you. You can use its ovulation calculator, get pregnancy tips and watch pregnancy videos.
- MoodKit: This app uses four tools — activities, checker, tracker and journal. All these are geared towards dealing with unhealthy thinking and promoting well-being.
- Talkspace: If you’re looking for therapy, this could be the mobile app for you. It matches you with a provider based on an initial assessment to ensure you get the treatment and support you need.
About the Author
- American Action Forum. "Chronic Disease in the United States: A Worsening Health and Economic Crisis." Accessed August 22, 2022.
- American Medical Association. "Trends in Heath Care Spending." Accessed August 21, 2022.
- Centers for Disease Control and Prevention. "About Chronic Diseases." Accessed August 22, 2022.
- HealthCare.gov. "Health Savings Account (HSA)." Accessed August 21, 2022.
- HealthCare.gov. "High Deductible Health Plan (HDHP)." Accessed August 21, 2022.
- International Forum for Wellbeing in Pregnancy. "Stress During Pregnancy Due to Financial Challenges." Accessed August 22, 2022.
- Kaiser Family Foundation. "2020 Employer Health Benefits Survey." Accessed August 21, 2022.
- Kaiser Family Foundation. "2021 Employer Health Benefits Survey." Accessed August 21, 2022.
- Kaiser Family Foundation. "Average Annual Deductible per Enrolled Employee in Employer-Based Health Insurance for Single and Family Coverage." Accessed August 21, 2022.
- Kaiser Family Foundation. "Can I Be Charged Higher Premiums in the Marketplace if I Smoke?." Accessed August 21, 2022.
- National Alliance on Mental Illness. "What You Need to Know About the Cost and Accessibility of Mental Health Care in America." Accessed August 22, 2022.
- National Center for Health Statistics. "Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January — June 2021." Accessed August 21, 2022.
- Peter G. Peterson Foundation. "Why Are Americans Paying More for Healthcare?." Accessed August 21, 2022.
- United States Census Bureau. "Income and Poverty in the United States: 2020." Accessed August 21, 2022.