Selecting a health insurance plan is among life’s most important decisions, affecting your health, finances, and future. If your employer offers insurance options, count yourself among the lucky ones. Unfortunately, if that’s not an option, shopping the healthcare marketplace can feel like navigating a labyrinth. Just searching “urgent care Philadelphia” won’t get you far enough; you need more insight and strategy.  

hospital emergency room

Continue reading for ten things that will empower you to choose your perfect plan.

1. Which Service Providers Are Accepted?

You may already have strong connections with doctors and hospitals or be looking for a new care team, whether it’s urgent care Philadelphia or another location. In either case, research which doctors and clinics are in-network, meaning covered by your insurance.

Before committing to a plan, contact your preferred hospitals and care providers to see what insurances they accept. Costs to receive care from out-of-network providers will be higher.

2. What is a Monthly Premium?

Know your terms to avoid confusion in the world of insurance. A monthly premium is the amount you pay to maintain membership on a health insurance plan, whether you use any services or not. 

A plan with a low monthly premium can be ideal for patients expecting to use health services sparingly. But make sure to dig deep into the fine print. These often have higher deductibles and out-of-pocket limits – not ideal for those with frequent care needs.

3. What is a Deductible?

A deductible is the share of medical costs you have to pay out-of-pocket in a given year before your health insurance provider begins covering the cost with you. 

On a plan with a $2000 deductible, coverage begins after you’ve crossed that threshold. From urgent care Philadelphia visits to standard check-ups, all medical care counts towards the total.

Plans with a lower premium tend to have higher deductibles. Note that some plans have deductibles for both general care and prescriptions, leading to even more out-of-pocket costs.

4. What Do the Different Tiers Mean?

The terms Bronze, Silver, Gold, and Platinum denote different tiers of cost-sharing, or the breakdown of responsibility for paying medical expenses. 

With a Bronze plan, your insurance provider covers 60% of the bill, and you pay 40%. This goes up to a 90%/10% split on a Platinum plan.

Platinum plans tend to have the highest monthly premiums but can lead to savings over the course of the year for those with frequent care needs. 

5. What is an Out-of-Pocket Limit?

The out-of-pocket limit is the upper limit in costs you will pay for covered medical expenses. 

Think of your insurance costs in three phases: 

  • In phase one, you cover all expenses yourself, until you’ve exceeded your deductible. 
  • In phase two, you share costs with your insurer, until you pass the out-of-pocket limit. 
  • In phase three, your insurer pays for all covered expenses.

The out-of-pocket limit is an especially important number to know. A plan with a high out-of-pocket limit can leave patients vulnerable to medical debt. 

6. What is The Difference Between an HMO and PPO?

An HMO, or health maintenance organization, is a plan that has a limited set of in-network hospitals and care providers. To see specialists, you will need a referral, and out-of-network care is more costly.

A PPO, or preferred provider organization, is more flexible. You can see out-of-network providers and specialists without a referral, and the costs will be partially covered. Depending on location and services, urgent care Philadelphia – or any other city – may or may not be covered. 

If your healthcare needs are simpler, an HMO may be the best choice. A PPO is great if you need a wider range of care.

7. Are You Covered for Your Current Health Situation(s)?

Consider your current healthcare situation. Do you anticipate you will have similar needs to last year? 

Although no one can predict the future, using years past as a guideline can be helpful for plan selection. Do your research to make sure you can seamlessly continue the care needs of you and your family. 

8. Are You Covered in the Case of an Emergency?

Life happens. Surprises come up. That’s why there’s a strong urgent care Philadelphia infrastructure and in other major cities, as well. Regarding your health, look into costs and coverages under your new plan – if and when an emergency arises.

Research what care you can receive at an urgent care facility instead of rushing to the ER. The average ER visit costs $750, while equivalent care from an urgent care facility typically costs around $200. 

9. What is the Plan’s Prescription Drug Coverage?

Two-thirds of American adults take prescription medications. Before choosing a plan, review its formulary, and the list of prescriptions covered. The formulary also lists the cost of these drugs to help you plan your budget. 

Read the fine print on your plan, as many require patients to try less expensive generic equivalents before covering the costs of brand-name drugs.  

10. Are You Eligible for a Tax Credit?

Health insurance is costly, but some patients are eligible to receive relief from the premium tax credit. 

If you have an income between 100% and 400% of the Federal Poverty Level, you likely qualify for this benefit. The credit can be applied to your monthly premium, or you can opt to take it out during tax season.


No one has a crystal ball, but educating yourself on the insurance system can help you make the most informed decision for your and your family’s future.