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Things to Consider When Evaluating Health Insurance Plans

​When it comes to evaluating health insurance plans, it is important to understand the benefits you are receiving in exchange for the premiums you are paying.

Here are some key points to consider when deciding on what is best for your family's needs.

Affordability (total cost)

  • Understand the fee structure of the plan options presented to you and how it relates to deductibles, copayments, coinsurance and selection of providers.
  • In general, if you pay less for insurance premiums, you will pay more in copayments, deductibles, etc.  You may also have a more limited choice of doctors and services.

Coverage & Benefits

  • Understand how the benefits relate to others obtaining coverage, not just how they relate to the person signing up for the plan (i.e. how will your children be covered?). 
  • Determine, in advance, how well the insurance plan covers your children and family members with special health care needs.
  • Identify any benefit carve outs. This is a management approach where a defined category of services or diagnoses (such as mental health or vision services) is not included in the benefit coverage. These services are contracted separately through agreements with a group of providers (typically a specialty managed care organization or single-specialty doctor independent practice association (IPA) and, as determined by service or diagnosis, may be paid for on a separately determined basis.
  • Make sure you understand what benefits are carved out of your plan and how you can maximize your benefits coverage for those services.
  • Review your plan annually, even if you have been covered for several years. Many plans will make changes to the coverage levels – some during the benefit plan year. Do not assume that your coverage will remain the same year after year.

Appeals Process

  • Understand the benefit plan appeals process and how it works. 
  • Most denials go unchallenged because members are not aware of their right to appeal or do not follow the appeals process as outlined by the plan.
Last Updated
American Academy of Pediatrics (Copyright © 2013)
The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.
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