What to Know About Shopping for a Health Insurance Policy

"We always say the biggest pitfall is looking at the premium alone," she says. But, she points out, low-premium plans might have higher deductibles, higher copays (the set fee you pay for services like doctor visits), and higher coinsurance (the percentage you pay, often 20%).

Instead of focusing only on the premium, Jones recommends reviewing your total potential health costs and figuring out your share (after insurance pays) for your medical visits, prescriptions, treatments, and other services. You can then see how much different plans will pay, which helps you pick which one to buy.

One key in comparing plans, she says, is to find out if your health care providers — your doctors, hospital, and pharmacy — will be in network with plans you're considering. If not, you could be paying quite a bit more.

For example, Jones says, if your in-network annual deductible (the amount you pay before benefits start) is $2,000, an out-of-network deductible, which is separate, could be $4,000 to $5,000. Copays for in-network services might be 20%, but out-of-network ones could be 50%.

"I don't think everybody realizes the difference and what that financially could mean if you do go out of network," Jones says.

Rising Insurance Costs and Alternative Plans

A big concern in health insurance this year has been the impact of higher ACA Marketplace premiums, since Congress opted not to renew subsidies that were put in place during the COVID-19 pandemic. In 2026, the median premium jumped about 20%, with a possible hike of 15% in 2027, according to a recent Peterson-KFF study.

Because of the price increases, some Marketplace subscribers haven't been able to keep their plans, Jones says, "so they're looking for other coverage options or going back to being uninsured."

Sabina McQuillan, 64, is a retired mental health therapist from Portland, Oregon, who gets her health insurance through her husband's employer. Each year, the couple pore over insurance options the company offers its employees.

Lately, such changes have meant higher deductibles — now $5,500 for the two combined — coupled with reduced benefits, McQuillan says. Neither she nor her husband has major medical issues, so their expenses all go toward the deductible. Then another year starts.

"The frustration is just a constant, low level," she says. "How are they going to get more money now? That's how it feels. How much more do insurance companies and pharmaceutical companies feel that they can squeeze consumers?"

McQuillan says she does her due diligence and researches insurance issues heavily before deciding which insurance option to pick. She looks up studies on Google Scholar and is wary of accepting any "AI answers," preferring to "dig a little deeper to make sure it's coming from reputable sources." (Damrow similarly says it's important to delve beyond the front-page summary of a plan to the fine print.) McQuillan and her husband also look at things like what the plan will pay for MRIs, CT scans, and prescription drugs.

Despite their efforts, she doesn't like their current plan. "We're not happy at all," she says.

Jones says high prices for Marketplace plans have led more people to try short-term alternatives that cost less but "have very, very limited coverage."

Original Medicare or Medicare Advantage?

If you're shopping for a Medicare plan, you'll find a big choice — whether to go with "original" Medicare or Medicare Advantage.

Both have pros and cons.

"There's no one best way for people to get Medicare coverage," says Julie Carter, counsel for federal policy at the nonprofit Medicare Rights Center. "It's very much a case-by-case basis."

If you opt for original Medicare, you'll have to buy a separate prescription drug plan and likely a Medigap supplement plan, which covers what Medicare doesn't, such as copays and coinsurance. With original Medicare, vision and dental plans aren't included, so you'd have to buy these separately. Prices for Medigap policies vary widely by state, Carter says.

Medicare Advantage plans have annual maximum out-of-pocket limits. Many cover services like prescription drugs, vision, and dental. They use provider networks, like PPOs and HMOs, which can be more limiting, especially if you travel. They also usually require approval before you get certain services ("prior authorization"), which can mean delays or denials of care your doctor may have ordered. Some health systems don't accept some Medicare Advantage plans — about 19% in a 2024 survey — with another 61% considering doing so. This likely is because doctors are paid about 10% to 15% less with Medicare Advantage than with original Medicare.

Both Medicare and Medicare Advantage follow the federal government's cap on out-of-pocket prescription costs, which is $2,100 in 2026 and will rise to $2,400 in 2027, Carter says. This means once you spend more than this on drugs, the plan will pay 100% of your prescription costs until the insurance period ends.

To see which type of Medicare is best for you, Carter recommends totaling up your expected health care costs and seeing how you'd fare under both types of plans.

Keep in mind that both Medicare and ACA plans only have certain times of year in which you can change or add plans. Open enrollment for Medicare is October 15 to December 7, while for the ACA Marketplace, it is November 1 to December 15 for coverage that starts January 1. Enrolling later, through January 15, pushes your start date to February 1. Some state-run Marketplaces set their own deadlines. (Some exceptions exist that allow you to make changes outside the open enrollment period, such as moving, marrying, or giving birth.)

How to Find Outside Help

If you find sorting through health plans too complex or time-consuming to do on your own, you may want to find expert help.

Health insurance agents or brokers are one option. Damrow hired an agent the first year she qualified for Medicare, because "the whole Medicare system was kind of confusing."

She chose a local agent who had been recommended by friends and had good online reviews.

We Can Help You, a nonprofit that assists people with Medicare and Social Security issues, recommends using independent agents, which are not aligned with specific insurers. We Can Help You suggests looking for agents via the Medicare Agent Finder and asking friends, family, and your doctor for referrals.

If you have a chronic, life-threatening illness, Jones' Patient Advocate Foundation may be able to help you shop for insurance. Or, depending on what your illness is, you may find insurance help with organizations focused on that particular condition, Jones says.

State and federal government also can help.

For assistance with ACA Marketplace policies, go to HealthCare.gov, put in your ZIP code, select "get local help," and get connected with an "assister" to help you navigate plans. Some states run their own Marketplaces; others let the federal government provide this service. The HealthCare.gov website will direct you to the right program.

To find specific Medicare plans that meet your needs, Medicare offers an online Plan Finder service. The Medicare Rights Center offers a national helpline (800-333-4114) to help walk you through the Plan Finder process; staff can also answer general questions about Medicare.

Another way to get guidance about Medicare plans is to contact the State Health Insurance Assistance Program (SHIP) in your state, by website or phone (877-839-2675). SHIP is staffed with trained volunteers that offer "one-on-one, unbiased counseling to help find the right plan," says Carter, who recommends their services.

If you find that no matter how hard you look, you can't find an affordable Medicare plan, you may be eligible for help from Medicare Savings Programs. These state-run programs can help cover premiums, deductibles, coinsurance, and copayments, depending on your income.