Whether you’re new to picking a health insurance plan, or you’ve already had to do it many, many times, it can be a bit of a slog. There’s so much to look through and many decisions to make, but it’s well worth taking your time and going through the trouble of choosing a good health insurance plan. The better the plan, the less you will pay each year for your medical care. That’s the hope, anyway.
Meanwhile, for anyone buying insurance off of the Health Insurance Marketplace, current events swirling around whether there will be an extension on the Affordable Care Act’s enhanced premium tax credits in 2026 has made buying a health plan even more uncertain and complicated. If that happens, some people will lose their tax credit, just as their health plan’s prices also climb. Some households are expected to see their premiums double, according to a KFF analysis.
So if you’re picking a health insurance plan but aren’t sure where to start or would like a refresher course, you could start here.
When to Pick a Plan
The last few months of the year is typically when most people are busy either renewing an existing plan or buying a new one, whether they’re enrolling in a plan provided by your employer, or signing up for a Medicare plan or purchasing a plan through the Health Insurance Marketplace.
Employer-provided coverage
In 2023, about 164.7 million Americans — 60% of the population under the age of 65 in the U.S. — had employer-provided health insurance, according to the most recent numbers from the Kaiser Family Foundation.
For people with employer-provided coverage, many companies set aside a two- to three-week enrollment period between October and November. The human resources department can really come in handy in these situations, says Leonard Spangher, vice president and senior health consultant at Segal, a human resources and benefits consulting firm headquartered in New York City.
Spangher says that if you’re struggling with picking the right plan through your employer, you can and should use the HR department to advise you on everything from everything from the maximum amount of money you’ll spend out of pocket to your copays and coinsurance to whether you should look into using tax savings vehicles, such as health flexible spending accounts and health savings accounts, that might help offset health care expenses that you’ll pay that your plan doesn’t cover.
[READ: Medicare vs. Medicare Advantage: How to Choose.]
Medicare
For the approximately 69 million people who have Medicare, the annual enrollment period runs from October 15 to December 7. Medicare is the government health insurance program that primarily provides health insurance for Americans age 65 and older. It also provides coverage for people with disability status (as determined by the Social Security Administration) and some younger people.
Medicaid
Medicaid is a separate federal and state program to provide coverage for people with limited income. There is no open enrollment period for Medicaid. You can enroll any time.
Health insurance marketplace
The time from November 1 to December 15 is what is known as the open enrollment period for Americans enrolling in a plan through the Health Insurance Marketplace, a service run by the federal government. The marketplace is where individuals, households and small businesses can select a health insurance plan from private insurers.
Consumers can sign up for coverage for the first time or change their existing plan during this period, with coverage kicking in on January 1.
The Affordable Care Act called for the creation of exchanges in each state, also called marketplaces, but how the policies are implemented varies by state. There are 21 state-based exchanges (SBEs), two state-based exchanges on the federal platform (SBE-FPs) and 28 federally-facilitated marketplaces (FFMs). The health insurance plans in what’s known as the Health Insurance Marketplace provide subsidies for some lower- and middle-class consumers, depending on their income.
Subsidies have been available for people who earn between 100% and 400% of the federal poverty level. For a family of four, that would mean an annual income between $32,150 and $128,600, according to the 2025 Poverty Guidelines published by the U.S. Department of Health and Human Services.
If the aforementioned tax credits expire at the end of the year, whether premiums go sky high or not, exactly how much more anyone will pay isn’t clear and will depend on your age, geography and income.
If you’re uncertain how the credits expiring will affect you, you should look for a plan regardless and try to find the best plan you can afford, advises Josh Schultz, based out of Austin, Texas, and the head of government affairs at Softheon, a Stony Brook, New York, tech company that provides software for health plans and government agencies.
“Tax credits aren’t disappearing,” Schultz says. “What’s at issue is whether the temporarily expanded tax credit subsidies will continue at their current levels. Even in a scenario where the enhanced credits expire, premium tax credits will still be available, they just won’t be as generous, and households above four times the federal poverty level would no longer qualify.”
“My advice is to choose a plan you can comfortably afford based on the prices you see during open enrollment on HealthCare.gov or your state’s exchange,” Schultz says.
He adds that if Congress extends the enhanced credits again, “federal policy would need to provide a pathway for consumers to upgrade their coverage.”
So for now, Schultz says, “Make the best choice with the information available today.”
[READ: How Adults Can Get Free or Low-Cost Vaccines]
Which Marketplace ‘Tier’ Is Right for You?
Marketplace health care plans are available in four categories: Platinum, Gold, Silver and Bronze.
“Metal tiers don’t reflect quality. They reflect how costs are split between you and the insurer,” Schultz says. “Traditionally, Bronze plans cover about 60% of the average enrollee’s costs, Silver covers 70%, Gold covers 80% and Platinum — where it still exists — covers around 90%.”
Platinum plans are becoming harder to find because, from what he has heard anecdotally, those plans have become unprofitable for the industry, he says.
In addition to the four tiers, certain patients meeting certain criteria can also select “catastrophic” plans, which are affordable options to protect yourself against worst-case scenarios.
But there are quirks about all of the plans that are important to consider. For instance, catastrophic plans may sound good, but they truly are for a catastrophe, to protect you from medical bills in case you, for instance, are in a car wreck and spend weeks in a hospital, and are generally only sold to people under 30 who are healthy. In most cases, you’ll have to pay the deductible before your insurance starts covering your expenses. In 2026, the deductible is $10,600.
So it’s not something to get lightly.
When evaluating which plan is best for you, consider your medical history. If you’re relatively healthy and typically have a low number of medical appointments, you may want to consider a lower-priced plan, particularly if you can afford higher out-of-pocket costs. Conversely, patients who are managing a chronic illness — such as heart disease, diabetes or cancer — may want to consider a higher-priced plan, typically Platinum or Gold, that offers lower out-of-pocket costs.
But, as noted, there are quirks with all of these plans, and if you make assumptions, you could end up spending more money than you anticipated.
“In many states, Gold plans can actually be less expensive than Silver plans,” Schultz says. “The key is not to assume the metal tier tells you the price. Compare them side by side.”
[READ: How to Shop for Health Insurance Covering Mental Health]
6 Key Elements to Consider When Buying Health Insurance
Whether you’re looking at a health care plan on the marketplace, through your employer or looking at a plan through Medicare or Medicaid, when evaluating different health insurance plans, it’s a good idea to consider these six key elements:
— The plan’s health care provider network
— Monthly premiums
— Deductibles
— Drug formulary (the list of prescription medications approved by the plan)
— Copayments
— Coinsurance
“When comparing plans, the most important thing to consider is how much care you realistically expect to need next year,” Schultz says.
From there, you’ll want to try to predict how the plan will interact with your budget.
“If you or a family member on the plan has ongoing health needs, such as expensive prescriptions, specialist visits, or a planned procedure, it often makes sense to choose a plan with a higher monthly premium but a lower deductible or out-of-pocket maximum,” Schultz says. “You’ll pay more each month, but you’ll spend far less when you actually use the system.”
“On the other hand,” Schultz adds, “if you’re generally healthy and only expect to use routine preventive care, you can place more weight on the premium and consider plans with higher deductibles.”
Dominic Morrone is an insurance broker with World Insurance Associates, headquartered in Iselin, New Jersey. He says that he advises his clients to look at three categories in particular when choosing a health plan. He suggests first making sure that you’ll be able to see your doctor on the health insurance plan. Morrone points out that some plans have restrictions that may limit who you can see.
Then, he suggests looking at the maximum out of pocket, often called MOOP. The MOOP is the highest amount of money you’re going to spend if you have a lot of health issues in a given year.
Finally, he says, you should examine the premiums and if they fit into your monthly budget. But Morrone points out that even then, you may be missing the full picture. If you’re getting a plan from the Health Insurance Marketplace, Morrone says that “Bronze plans require the deductible being paid first by the policy holder before the carrier pays claims.”
So if you’re not expecting having to pay off the deductible first, before your insurance really kicks in, that could derail your budget.
It’s also a good idea to learn about each plan’s copayments, which is a fixed amount paid when you seek health care, and to look at what the plan’s coinsurance is. That’s the percentage you will owe on the total cost of a particular service.
[HSA and Medicare: Using HSA To Pay for Medicare Premiums]
Think About Unexpected Costs
“In general, the more a plan costs, the more protection it should offer,” Spangher says.
And Spangher observes that it “costs more to protect against larger unforeseen health expenses.”
So if you really want to be well protected from hefty medical bills, you probably do want to spend a little more on your plan than get a bare bones one.
Special Enrollment Period
People who purchase marketplace insurance but miss their state’s open enrollment deadline may still have an opportunity to get insurance for the year. Those who have experienced certain life events — such as losing health insurance coverage, moving to another location, getting married, having a baby or adopting a child — qualify for a special enrollment period. The timing depends on the specific circumstance, but consumers may have as much as 60 days before or after the event to enroll in a plan.
Possible Tax Penalty
Initially, the Affordable Care Act included a penalty for not obtaining health insurance. While you can no longer be penalized for being uninsured on a federal level (that rule ended in 2018), some individual states still enforce those mandates. If you live in California, Massachusetts, New Jersey, Rhode Island (or in the District of Columbia), you may pay a tax penalty for not having health insurance.
[SEE: Medicare Grocery Allowance: What It Is and How to Get It]
Wellness Incentives
Many plans now offer financial incentives that reward you for taking healthier actions, such as completing a health survey, improving your fitness by exercising or avoiding nicotine. Some plans offer gym memberships and wellness programs for members at no additional cost. These are definitely not perks that you’d want to consider first. Mainly, you should look at the aforementioned expenses such as how much the MOOP is and the premium and what the co-payments are. But if you’ve narrowed your plan down to two or three, those wellness incentives may make your choice a little easier.
But if you’re looking exhaustively at health insurance plans, pat yourself on the back: you’re ahead of where a lot of people are, according to Spangher.
“It’s been said that people spend less time choosing a health plan than they do planning a vacation or buying a computer,” he says.
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How to Pick a Health Insurance Plan: Your Open Enrollment Guide originally appeared on usnews.com
