Things to consider when shopping for an individual plan on SureCo's site:
1. Cost & Budget
How much can I comfortably afford deducted per paycheck?
Would I rather pay more per paycheck for lower out-of-pocket costs — or less each paycheck and pay more only if I need care?
The prices displayed in SureCo's platform take into consideration your employer's ICHRA contribution and are the amounts that will be deducted from your paycheck each pay period.
2. Care & Usage
How often do I visit the doctor or specialists?
If I go frequently, do I want a plan with copays for office visits right away?
If I rarely go, am I comfortable paying the contracted rate out-of-pocket until my deductible is met?
Do I need access to specific doctors, hospitals, or medical groups?
Have I checked whether my preferred providers are in-network?
SureCo uses a third party to check provider participation. If you see a green checkmark next to the provider your entered, the third-party vendor believed they are in network on that plan. Please verify with your provider to be sure
If you see a yellow triangle, that does not mean that the provider is not contracted on that plan but that they could not be verified. Please call your provider to verify if they are in network.
3. Medications
Do I take maintenance medications, generic, or brand-name prescriptions?
Have I checked if my prescriptions are covered on the plan’s formulary (drug list)?
If you select "Benefit Summary" and scroll down to the drug coverage section, a link to that plans formulary will be available on the left-hand side prior to the copay information.
Do I prefer to use a certain pharmacy?
4. Timing & Eligibility
Am I enrolling during the Annual Open Enrollment Period roughly (Nov 4th thru Nov 26th), or do I have a Special Enrollment Period (QLE) like marriage, birth, or loss of coverage. etc?
Do I have proof of my Qualifying Life Event also known as supporting documentation ready to submit if needed?
5. Coverage Basics
Do I understand what my deductible, copays, coinsurance, and out-of-pocket maximum mean — and how they affect what I pay?
Am I comparing HMO, PPO, EPO, or POS plan types to see which gives me the flexibility I want?
Do I have an active HSA account and want a plan eligible to continue contributing?
What are the different plan types available?
1. HMO — Health Maintenance Organization
Best for: Lower costs and coordinated care with a primary doctor.
You must choose a Primary Care Physician (PCP) who coordinates your care.
Referrals are required to see specialists.
Out-of-network care is not covered, except for true emergencies.
Typically has lower premiums and out-of-pocket costs.
Example: You see your PCP for a referral before visiting a dermatologist.
2. PPO — Preferred Provider Organization
Best for: Maximum flexibility to see doctors without referrals.
No referrals are needed to see specialists.
You can see any provider but pay less when using in-network doctors and hospitals.
Offers out-of-network coverage, though it costs more.
Usually has higher premiums due to greater flexibility.
Example: You can visit an orthopedic specialist directly without needing PCP approval.
3. EPO — Exclusive Provider Organization
Best for: Lower cost than PPOs with moderate flexibility.
No referrals are needed for specialists.
Only covers in-network care, except for emergencies.
Often has lower premiums than PPOs, but fewer network options.
Example: You can schedule a specialist visit directly, as long as they’re in-network.
4. POS — Point of Service
Best for: Balance between HMO structure and PPO flexibility.
You select a Primary Care Physician who coordinates your care.
Referrals are needed for specialists.
Out-of-network care is covered, but at a higher cost and requires more paperwork.
Example: You can see an in-network cardiologist with a referral or go out-of-network and pay more.
5. HSA — Health Savings Account (Paired with a High-Deductible Health Plan)
Best for: People who want to save pre-tax dollars for medical expenses.
Must be paired with a High-Deductible Health Plan (HDHP).
Allows you to contribute pre-tax money to an HSA account for medical expenses.
Unused funds roll over each year and stay with you even if you change jobs.
You pay for most care out-of-pocket until your deductible is met, but premiums are typically lower.
Example: You use your HSA funds to pay for prescriptions or doctor visits until your deductible is met.
Understanding Health Insurance Costs
When you use your health insurance, you share the cost of care with your insurance company. These shared costs come in a few main forms: deductibles, copays, coinsurance, and the out-of-pocket maximum.
1. Deductible
Your deductible is the amount you must pay out of your own pocket each year before your insurance starts to share the cost of most covered services.
Once you meet your deductible, your plan begins to pay part of your costs (through coinsurance or copays).
Some services—like preventive care or certain doctor visits—may be covered before you meet your deductible.
Example:
If your deductible is $2,000, you’ll pay the first $2,000 of covered medical expenses yourself before your plan starts paying its share.
2. Copay
A copay (or copayment) is a fixed dollar amount you pay each time you receive certain services or prescriptions.
Copays usually apply to doctor visits, urgent care, or prescriptions.
You typically pay the copay at the time of service, and it does not usually count toward your deductible, though it does count toward your out-of-pocket maximum.
Example:
You might pay a $25 copay when you visit your primary care doctor or $10 for a generic prescription.
3. Coinsurance
Coinsurance is your share of the cost for a service after you’ve met your deductible.
It’s expressed as a percentage, not a flat amount.
Your insurance company pays the remaining percentage.
Coinsurance continues until you reach your out-of-pocket maximum.
Example:
Your plan has 20% coinsurance after the deductible.
You’ve met your deductible, and you have a $1,000 hospital bill — you pay $200 (20%), and your plan pays $800 (80%).
4. Out-of-Pocket Maximum
Your out-of-pocket maximum is the most you’ll pay in a year for covered medical expenses.
Once you hit this limit, your insurance pays 100% of covered costs for the rest of the year.
Example:
If your out-of-pocket max is $7,500, once you’ve paid that amount in deductibles, copays, and coinsurance combined, your plan covers all eligible care at no additional cost to you.
How They Work Together
Here’s how these terms fit together in real life:
You pay 100% of medical costs until you meet your deductible.
After that, you pay copays or coinsurance for covered services.
Once your total payments (deductible + copays + coinsurance) reach the out-of-pocket maximum, the insurance pays 100% of covered costs for the rest of the year.
***Always refer to the plan's Summary Benefit Coverage for details related to the specific plan you are electing.
Comments
0 comments
Article is closed for comments.