by Rhea Bautista, MD, MBA
Choosing a health insurance plan can feel overwhelming, but most people can start by looking at four key areas: costs, medications, doctors and specialists, and travel coverage.
First, look beyond the monthly premium. A plan with a low monthly cost may still be expensive if it has a high deductible, high copays, or high coinsurance.
The deductible is the amount you may need to pay before the plan begins covering many services. Copays are set amounts, such as a fee for a doctor or specialist visit. Coinsurance is when you pay a percentage of the cost.
Before choosing a plan, ask yourself: “What will this cost me when I actually need care?”
Second, review your medications. Every plan has a list of covered drugs, often called a formulary. Medications are usually placed into different tiers, and each tier may have a different cost.
If you take prescriptions regularly, check whether each medication is covered, what tier it is in, whether prior authorization is needed, and how much you will pay at the pharmacy.
This step is especially important for people with chronic conditions or multiple prescriptions.
Third, check your doctors and specialists. In Hawaii, access to care can depend on your island, your provider network, and the number of specialists available. Make sure your primary care doctor, preferred clinic, hospital, and specialists are in the plan’s network. Also, check the copay for specialist visits and whether you need a referral.
This matters for patients who see cardiologists, kidney doctors, cancer doctors, neurologists, behavioral health providers, or other specialists.
Fourth, think about travel. Many Hawai‘i residents travel to the mainland for family, school, work, or medical care. If you travel often, check whether the plan covers care outside Hawaii. Some plans may cover emergencies on the mainland but not routine visits or follow-up care.
Ask whether mainland urgent care centers, hospitals, or doctors are in the network and whether approval is needed before receiving care away from home.
People who have Medicare and Medicaid, sometimes called Medi-Medi, should also ask whether they qualify for extra help.
The Low-Income Subsidy, also called Extra Help, may lower prescription drug costs for people who qualify. This can make a major difference for patients who take several medications or have expensive prescriptions.
For families, the best plan is not always the cheapest plan. One family member may only need annual checkups, while another may need regular medications, lab tests, specialist visits, or care while traveling. Compare the plan based on the needs of the whole household.
Health insurance is meant to protect both your health and your finances.
Before choosing a plan, take time to compare the deductible, copays, coinsurance, medication costs, provider network, specialist access, travel coverage, and any financial assistance you may qualify for.
In Hawaii, where access can vary by island and provider network, the right plan is the one that gives you the care you need at a cost you can understand and manage.
Health Insurance Checklist
Before choosing a plan, check the following.
Monthly premium: How much will you pay each month?
Deductible: How much do you pay before the plan starts covering many services?
Copays: How much do you pay for primary care, specialist visits, urgent care, and emergency care?
Coinsurance: Will you pay a percentage of the cost for certain services?
Medications: Are your prescriptions covered?
Drug tiers: What tier are your medications in, and how much will they cost?
Pharmacy access: Can you use your regular pharmacy?
Primary care doctor: Is your doctor in the plan’s network?
Specialists: Are the specialists you need available and in network?
Specialist copay: How much will each specialist visit cost?
Referrals: Do you need a referral before seeing a specialist?
Hospitals and clinics: Are nearby hospitals and clinics covered?
Neighbor island access: Can you get the care you need on your island?
Travel coverage: Does the plan cover care on the mainland?
Emergency care: What happens if you need urgent or emergency care while traveling?
Medi-Medi: Do you qualify for both Medicare and Medicaid?
Extra Help: Do you qualify for the Low-Income Subsidy to help pay for medications?
Family needs: Does the plan work for everyone in your household?
RHEA BAUTISTA, MD, MBA is a healthcare strategist and entrepreneur serving as Director of Business Strategy and Growth at MDX Hawai‘i, co-founder of SB Solutions, and Executive Director of the Philippine Medical Association of Hawai‘i. She also advises the Primary Care Clinic of Hawai‘i on quality improvement.
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