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What are the important factors when deciding which policy to purchase?   We call those factors, the “drivers”:   price, hospital networks/doctor networks, and medication coverage.   Not all come into play when deciding, but without a doubt, one or a combination of these determine the decision to purchase your coverage.


The first driver for most consumers is price.  We are all looking for the most competitive rates particularly when purchasing insurance.  The factors that affect rates are going to be size of doctor and hospital network, and to some extent how often is the deductible exposed on day to day usage. A good question to ask your agent or when reviewing benefits is understanding which services are strictly based on co-pays and on which services you must first meet your deductible before the insurance kicks in.

Hospital and Doctor Networks

It is not uncommon to verify that specific hospitals are in the network of the carriers you are considering.  Many consumers have individual preferences and will request that a specific hospital is covered in the event of a planned procedure.  A planned procedure is when your doctor or specialist makes arrangements for an in-patient or out-patient hospitalization.  Make sure that emergencies are considered in-network. This is critical as in the event of a life threatening medical emergency no one has time to remember which hospitals are covered within the carrier network.

Availability of doctor networks has been a contentious subject since the passing of the law and a source of confusion for both doctors and consumers.  Many doctors claim to be within specific networks and are not; others state the opposite – that they are not in any networks when in fact they are listed under a number of carriers.  This back and forth, coupled with the fact that the increase in traffic has delayed routine prevention appointments has frustrated everyone.  If you must have access to a specific doctor, ask your agent to research the networks and if calling the doctor’s office, make sure to explain that you are interested in their affiliation with individual carriers on and off exchange.  We have heard from both clients and doctors that they don’t want or do not take Obamacare when all health insurance in this country is now under the law, therefore it is all Obamacare.


If you are taking medications for the treatment of a chronic condition make sure to mention these to your agent. This is not for underwriting or pre-existing condition placement.   Not all medications are covered in equal terms by the carriers.   Insurance companies classify medications on a tier system, 1, 2, 3, 4 and specialty drugs.  Generics are for the most part Tier 1 and the least expensive, whereas specialty drugs might have a deductible and or co-insurance.  Check and make the math as regular prescriptions might have an impact on your expenses.  Keep in mind however that the out of pocket maximum, includes every dollar you spend on a calendar year on healthcare, (not your premiums) and will accumulate in a “bucket.”  When you hit that limit you will have no more medical expenses for the year.

Affordable Care Act Plans