2021 Step-by-Step Guide for Comparing Health Plans

Revised: Nov 30, 2020

Your health insurance decision can impact your health and finances for the year.

Choosing the right insurance is a judgement call based on what is covered, what is not, how much flexibility you want, and how you prefer to spread health care costs throughout the year. The content is adapted from the Patient Advocate Foundation (PAF) step-by-step guide. The work sheets help you organize your needs and compare plans on the Exchanges.

4 Steps to get you started.

Step 1

Gather the names of the doctors that are important to you now and all the prescription medications you are taking. This will be helpful to make sure that the plan
you choose covers your preferred doctors and medications. This planning can also help you avoid unexpected costs. The worksheets provided will help you organize the information
needed to compare plans.

Step 2

Enter the requested information about you on the official Health Insurance Marketplace website. Enter your zip code to find plans in your area. You may be
redirected to a different web page if your state runs its own exchanges.

Tip: Plans may be more affordable than what you first see in the estimates. Depending on your income level, you may be eligible for financial assistance that helps pay part of your
premium. To find out more about this assistance (called “estimated savings”), enter your annual household income before comparing plans to see rates personalized for you.

Step 3

Use the filter feature to narrow down the plans to a manageable number for comparing. Some options you can filter by:

• Monthly premium: select a reasonable range you can afford for this recurring fee.
• Yearly deductible: consider the amount you can afford to pay up front for medical care before the insurance kicks in to cover costs.
• Medical providers and prescription drugs: see which plans cover your preferred doctors, pharmacies and the medications you take.

Step 4

Pick a few plans you want to compare and use the worksheets provided below to help identify which ones meet your particular needs. To calculate your full expected costs and see
more plan details on healthcare.gov, select a plan, then click Plan Documents and you will find the following:

• Summary of benefits and coverage outlines what the plan covers and the costs you would be responsible for paying.
• Provider directory is where you can check whether your preferred doctors, hospitals and other facilities (like labs for bloodwork) are included in your plan, and
• List of covered drugs (called a “formulary”) provides information about prescription medications that are covered under the plan and the tier level, which
determines how much you would have to pay out-of-pocket to get your prescription.

Doctor and Hospital Considerations

The doctors and hospitals that are covered in the plan (called “in-network”) may change each year, so you’ll want to check that they are still in-network. This is a good time to think about any
changes you would consider, including the possibility of seeing a different doctor. If your doctor is not covered in-network, would you be willing to see another doctor or visit
another facility that is in-network? If no, does the plan pay anything towards the costs of seeing doctors or visiting hospitals that are out-of-network? You may still be able to see that doctor,
but it is likely that you will pay a higher out-of-network cost or be responsible for 100% of the costs. You can also contact your doctor’s office to ask about any special arrangements that may
be offered if the practice is not participating as covered providers on the insurance plans that you are comparing.

Prescription Medicine Considerations

This is also a good time to review with your doctor all the medications you are taking. You can go through your list of prescriptions, the amount you are spending for each, talk about how
these medications make you feel, and discuss whether any changes are needed. In some cases, a more effective or lower cost medication may be available, or your doctor may suggest
discontinuing some prescriptions that are no longer needed.

Doing a medication review annually with your doctor will help you get the best care possible and may also help you reduce your out-of-pocket spending on prescription medicines. You may
have the option to save money by switching from a brand drug to a generic drug. If you want to learn about cost-saving options that may apply for your medication, review this PAF resource
about drug tiering.

If you have been diagnosed with a complex or chronic condition, Patient Advocate Foundation’s (PAF) case managers can help guide your plan choice process.
The worksheets provided below can help you prepare for your conversation with your doctor’s office or with PAF case managers.

For personalized help, go to http://www.patientadvocate.org or click here to fill out the PAF request for assistance form.

You can also visit the PAF National Financial Resource Directory to find nationwide financial assistance support for medications, other health care needs and non-medical daily living

Worksheet 1. Your Doctors

List the names of each doctor and specialist important to you. For example: List out your primary care doctor, OBGYN, oncologist, psychologist

Worksheet 2. Your Hospital and Facilities

List the hospitals or facilities that you would want to go to for a planned procedure or an emergency in the numbered boxes below. For example: labs, outpatient centers,
urgent care, or emergency department.

Next to each name, write yes or no to indicate whether your doctors and specialists are included in the provider directory for each plan you are comparing.

Write yes or no to indicate whether the hospitals or facilities are on the provider directory list.

Worksheet 3: Your Medications

List all the medications you take in the numbered boxes below. For each prescription, check the list of covered drugs (called the “formulary”) and write yes or no to indicate
whether your medication is included in the formulary. You may also want to note which cost tier the medication is listed under to compare that information across the plan

Worksheet 4: Your Costs

To estimate the total costs associated with the various plan options and how it relates to your particular financial circumstances, list below the fixed costs each year that you
would be responsible to pay in monthly premiums, annual deductible and annual out-of-pocket limit (or maximum). Along with your out-of-pocket costs, these are the
numbers that matter when determining what you can expect to pay in total for the year. This information can be found in the plan’s Summary of Benefits and Coverage
document (sample here from the Centers for Medicare and Medicaid Services.) It’s difficult to know exactly what costs may occur ahead of time, especially if you receive an
unexpected diagnosis. But based on what you know about your finances and circumstances, it helps to try to estimate what you feel you can afford, so you select the
best coverage option for your needs.

1. Monthly premium ($ per month): Account for any estimated financial assistance you may be eligible for to help offset your costs. You can
estimate this here. Actual financial assistance is determined when you apply for coverage.
2. Annual deductible ($ per year) The amount you pay up front before the insurance starts to pay for care. Check if there are separate
deductibles for specific services or medications.
3. Out-of-pocket limit or maximum ($ per year) This is the maximum amount you would have to pay in total each year. It does not include premiums or
money spent on non-covered services. In addition to these fixed costs, once you have reached the deductible, you will have to pay a portion of medical expenses when you get care (called “cost sharing” or “out-of-pocket costs”) through either the copayment (a flat $ dollar fee) or coinsurance (% percentage of cost). Before this point, you will be responsible for whatever the doctor or hospital charges you on your own.

Below are some of the services you may need, but review the Summary of Benefits and Coverage to see how much you would pay for various other services.

4. Doctors ($ or %) – Primary care provider who you see for annual checkups.
5. Specialists ($ or %) – Specialty doctors like dermatologists, rheumatologists, or oncologists.
6. Hospital stay (%) – Emergency room care and facility fee if you must stay overnight.
7. Prescription Medicines per fill ($ or %). This depends on a few things like the plan’s formulary and what tier the medicine is placed on. Learn about the tiering options and how to request an exception at this PAF resource.

Bringing it All Together and Choosing Your Plan

Evaluate each plan against what you have determined are important doctors, medical services and prescription medicines to be covered, and your budget. Consider whether
you can afford the fixed costs (monthly premiums and deductibles) but also the cost sharing (coinsurance and copayments) when you receive care. While you typically won’t
pay more than the maximum out-of-pocket limit, consider whether you can afford to shoulder the upfront costs and pay the deductible over a short period of time if an
emergency arises.

Tip: Look at the plan’s monthly premium, annual deductible and cost-sharing as three equally important components affecting your total costs. For example, if a plan’s
monthly premiums are very low, then the deductible or copayments may be higher. Weigh these three components carefully aiming to strike the right balance for you before
selecting a plan.

Patient Advocate Foundation

One of the very best resources of  free help and financial assistance in the U.S. Get help navigating your health insurance, accessing treatments, appealing insurance denials, and connecting to care through the Patient Advocate Foundation, or call 800-532-5274. Go to https://apatientsplace.wordpress.com/help-guidance/ for hundreds of links to free help with your healthcare.

11 Essential Tips for Consumers to Get High Quality Healthcare


1. Be involved in all parts of your healthcare.

2. Ask questions whenever you are unsure of anything related to your healthcare.

3. Find out how much you will be expected to pay before appointments, tests, and treatments are started.

4. Request copies of your test results, doctor’s notes, and medical record when you check in for any appointment, test or treatment.

5. Always find out how much successful experience your health providers have at diagnosing and treating your specific condition.

6. Keep and organize copies of your medical records, test results, and interactions with all of your health providers.

7. Learn as much as you can about your illness and providers from trustworthy sources.

8. Contact your insurance provider as much as is needed to understand your coverage, your insurance provider’s guidelines, and your financial responsibilities.

9. Negotiate fees with doctors and treatment providers whenever possible.

10. Review your bills for mistakes, or have someone do it for you; its free.

11. Consult an experienced specialist after a serious diagnosis.

Get free help navigating your health insurance, appealing insurance denials, and accessing care through the Patient Advocate Foundation, or call 800-532-5274. Go to https://apatientsplace.wordpress.com/help-guidance/ for hundreds of links to free help with your healthcare.

Winning Health Insurance Coverage Denials

Last Revised: 02/12/2019


If you know someone who needs help with their health care finances, you can help them by sharing this link to free resources that are available for anyone.

How do you know if your claim for treatment was denied?

An Explanation of Benefits (EOB) which is sent to you by your insurance company is one of the only ways to determine what the insurance paid, and how much you may still owe. The EOB should also disclose if your claim has been denied.

If the insurance company portion of the payment shows $0, this can indicate that they denied your claim. The payment amount should be followed by a “Reason Code(s).” This code provides an explanation for the lack of payment. The insurance company may also send you a letter confirming the denied medical claim and detailing their reason(s) for denial.

Make sure to keep copies of all correspondence you receive from the insurance company, including denial letters, approval letters, your health history, medical files, doctor’s letters, etc. Always keep written records of all contacts and phone calls with the insurance company; including the name(s) of the people that you spoke too.

A Coverage Denial is not the Final Word

Many insurance companies deny claims simply because they know there is a good chance the policy holder will not fight back, or appeal.

If your insurance company denies coverage, follow the steps below:

Step 1: Check your plan to make sure the benefit you want is included. Make a note of the part of the policy that leads you to believe your claim should not have been denied.

Step 2: Collect and organize all information pertaining to the denied claim. Make sure you have the original bill with the date of service and the provider’s name, your EOB, and your insurance card before placing a call. If the insurance company sent you a letter, have that available as well.

Step 3: Call the number provided on the letter from your insurance company, or if you did not receive a letter the customer service number. There is a possibility the claim was denied because of missing information. Once the missing information is provided the claim will be re-processed, and hopefully you are done.

Step 4: Sometimes claims are denied because of improper coding. If that’s the case, ask your doctor to review the coding and re-submit a request with more specific medical justification for the procedure or medication, and you should be done.

Step 5: If your claim was not denied for missing information or improper coding, find out why it was denied, and how you can file an appeal.

Step 6: Ask the insurance provider’s representative for suggestions or guidelines for appealing a denial.

Step 7: If you would like an appeal form, ask them to send one via the mail or email.

Step 8: Make sure you have the address for the appropriate department to return the completed appeal documents.

Step 9: Always keep a record of the date, time, and the name of the insurance provider representative you talked with, along with a summary of the discussion. Keep this with copies of any documents you send to the insurance company.

Step 10: In appealing the denied claim, you should have the opportunity to review the information the insurance company used to make their decision.

Step 11: If necessary, get your doctor involved. To win an appeal you’ll likely have to to prove that the test or treatment is “medically necessary” and “scientifically proven.” Your doctor’s office should have staff that can help.

Step 12: Get help wording your appeals so that they mention medical problems, and do not include words that automatically trigger denials. Talk to the person who handles insurance claims at your doctor’s office. This person may be able to help you with the appeal process, and they may provide any documentation your insurance company requires.

Step 13: Remember each insurance company has its own appeal process. Before submitting your information, make sure you have completed and include the required paperwork. Once the documents are complete make a copy of everything for your reference.

Step 14: Continue to go through all levels of appeal.

Step 15: If your insurance company denies the claim again, in most cases you can contact them to request an external appeal. Usually, this appeal will be conducted by a medical professional or group of medical professionals not associated with the insurance company.

Step 16: Sometimes it takes the threat of a lawsuit to get your insurance company to move.

Send your correspondence to the insurance company via certified mail with return receipt. Be persistent. Remember that a denial is not necessarily the final word. Request in writing that your insurance company to reconsider their decision.

Contact your health insurance company within a reasonable amount of time if you don’t receive a written response that includes a justification. If you’re denied again and you believe that this is not consistent with your policy, contact your state insurance commission. That agency can mediate a dispute between you and your insurance company. If you win, you could save yourself hundreds or even thousands of dollars.

Medicare appeals need to follow a separate, federal appeals-review process.  There are detailed instructions for each level on the CMS website.