Don’t Sign Up for Private Health Insurance Plans 2025 Until You Ask These 10 Crucial Questions -

Introduction

We get it—health insurance feels like navigating a maze blindfolded. Private plans aren’t cheap or simple, whether you’re shopping in Canada or the US. But hold off on signing that dotted line! Knowing what questions to ask upfront can mean the difference between solid coverage and shocking bills. In this post, we’ll walk through the 10 critical questions you must ask before buying a private health insurance plan in 2025, helping you make an informed, budget-savvy choice.

Why These 10 Questions Matter (Especially in 2025)

2025 is shaping up to be a rollercoaster year in health insurance:

In the US, premiums under the Affordable Care Act (ACA) are set for their steepest increase in seven years, thanks to expiring subsidies and system changes Investopedia.
Many Americans may see a 15–28% jump in costs—or even higher if subsidies vanish MarketWatch+1.
In Canada, private plans still matter—for newcomers facing waiting periods up to 3 months, and for residents who want extra coverage beyond provincial plans Wise Movepolicyadvisor.com.

In short, this year, what you don’t question now could cost you tens of thousands later. Let’s demand clarity.

The 10 Must-Ask Questions Before Signing Up

1. What are the Premiums, Deductibles, and Out-of-Pocket Maximums?

It’s easy to fixate on the monthly premium, but that’s just the tip of the iceberg. Deductibles are what you pay before insurance kicks in, and coinsurance can still add up—even after that. In the US, a C‑section could end up costing you $5,800 out-of-pocket under a typical plan AP News.

In Canada, private plan premiums vary widely—typically CA$60–200/month depending on your age and coverage level policyadvisor.com.

Why it matters: Knowing how much you’ll spend before and after breaking the deductible helps you budget realistically.

2. Are My Preferred Doctors, Hospitals, or Therapists “In-Network”?

Calling your therapist or doctor only to learn they’re out-of-network—like that one cancer patient who faced nearly $2,000 in denied claims—can be a nightmare MarketWatch.

Action step: Ask for the in-network list and confirm individual providers—even if the insurer’s website says “yes.” Always double-check with both parties.

3. What’s the Prescription Drug Coverage (Formulary)?

Drugs aren’t generic when it comes to coverage.

In the US, plans vary by tiers, and what you paid previously might now cost a fortune.
In Canada, coverage is similarly variable—some plans only cover generics, others offer generous limits for brand-name medications.

Tip: Bring a list of your current medications when comparing plans.

4. What Does It Cover (Dental, Vision, Mental Health, Rehab, Travel)?

Public healthcare in Canada doesn’t cover things like dental, vision, or physiotherapy. Private plans fill that gap—but how much?

Ask specifics:

Preventive vs. restorative dental
Vision care limits (e.g., $200/year or 100% coverage)
Mental health: Is outpatient therapy covered, or are there session caps?
Emergency travel care if you travel frequently

5. How Are Pre-Existing Conditions Handled?

In the US, the ACA bans denying coverage for pre-existing conditions—but only in compliant plans Wikipedia. In Canada, many private plans may exclude or load for pre-existing issues unless it’s a guaranteed-issue plan.

Pro tip: Ask if a guaranteed acceptance option is available (though pricier), or if waiting periods exist.

6. What Type of Plan Is It (HMO, PPO, EPO, HDHP)?

Different plan types offer different balances of flexibility, cost, and referral requirements:

HMO: Lower cost but less flexibility—must stay in-network, need referrals
PPO/EPO: More choice, higher premiums
HDHP (High-Deductible Health Plan): Lower premiums, bigger deductibles

In the US, knowing your plan type helps choose one that matches your habits and lifestyle Vox.

7. What Are the Claims Processes and Appeal Policies?

If a claim is denied, what can you do?

The ACA mandates appeals, but timelines and processes vary Wikipedia.
In Canada, providers like Sun Life walk you through claims—but is direct billing available, or do you submit receipts yourself? Sun Life.

Tip: Choose insurers with seamless mobile or online claims tools and good customer reviews.

8. Are There Additional Tax Advantages or HSA/HRA Options?

In the US, Health Savings Accounts (HSAs) or Health Reimbursement Accounts (HRAs) can give tax benefits alongside insurance—valuable if you’re on a high-deductible plan Wikipedia.

In Canada, a Private Health Services Plan (PHSP) is an alternative structure that may offer tax-deductible health coverage for small business owners.

9. What Future Changes Could Affect My Plan?

We know costs are rising in 2025:

US: Enhanced tax credits are phasing out; insurers are requesting 18% increases in premiums for 2026 Investopedia.
Some states could see 28% hikes in premiums if subsidies disappear.
In Canada, newcomers know coverage begins after up to 3 months—but provinces vary Wise Move.

Ask:

Are my benefits locked in for 12 months?
Can premiums increase mid-year?
What happens if subsidies or regulations shift?

10. How Do Private Plans Compare to Marketplace Options or Provincial Plans?

In the US, marketplace plans may be subsidized and standardized (bronze, silver, gold), offering predictable benefits at affordable rates.

In Canada, provincial public plans handle essential care—private is supplemental. Depending on needs, workplace benefits or direct purchase might be better Canada Life.

Comparison Table:

Question	Private Plan	Public/Marketplace (USA)	Provincial (Canada)
Premiums & Out-of-Pocket	Variable, often higher	Standardized, may be subsidized	Provincial taxes, no premiums
Provider Networks	Narrower, need verification	Defined tiers, network varies	Provincial (broad public hospitals)
Drug Coverage	Depends on plan	Standard formulary tiers	Varies by province, often limited
Extras (Dental, Vision, Travel)	Often included	Limited or none	Not covered publicly
Flexibility	High variability	Standard plan options	Public system only
Tax/Treatment Options	HSA/PHSP possible	Tax credits/subsidies	No, except workplace benefits