Health Insurance Questions to Ask Clients
Twenty discovery questions for a broker or agent sitting down with a health insurance client, in the order a first appointment usually runs: what they have now and why, how much care they actually used last year, the doctors and prescriptions they will not give up, who needs covering, income and cash flow, past claim trouble, and how they decide between two plans. Written for the fact-finding conversation before you quote anything.
20 questions, each with the reason to ask it · includes a conversation guide
The questions
Open any question to see why it works.
- 1
What is covering you right now, and how did you end up on that plan?
The second half is the useful half. A plan chosen deliberately gets a different conversation from one inherited from an employer, kept out of inertia, or picked in ten minutes on a deadline, and the third case usually means nobody has ever checked whether their doctors are in network.
- 2
What made you look at this now?
Sets whether this is a renewal review or a problem to solve. A specific trigger, a denied claim, a doctor leaving the network, a job ending, tells you what the client will judge your recommendation against, and it is rarely the premium.
- 3
Walk me through last year: how many times did anyone on the plan see a doctor, and did anyone end up in a hospital?
Asking for last year's actual visits beats asking how much care they expect to use, because people describe themselves as healthy while forgetting eight visits. Zero claims in two years and a chronic prescription in the same household is a contradiction worth resolving.
- 4
Which doctors or clinics would you be unhappy to lose?
Names, not a general preference for choice. This is the constraint that most often eliminates the cheapest plan, and the one clients are angriest about discovering after enrollment. Ask for the specialist and the hospital as well as the family doctor.
- 5
What prescriptions is anyone on the plan taking, and what do you pay for them now?
The current out-of-pocket cost tells you what tier they are on today and gives you a comparison point. A single specialty or brand-only drug can outweigh every other difference between two plans, so get spelling and dose rather than a description.
- 6
Is anyone on the plan being treated for something ongoing, or waiting on a procedure?
Pending surgery changes the arithmetic completely, because a deductible reset mid-treatment can cost more than a year of higher premiums. It also raises timing: a procedure already scheduled may be worth finishing on the current plan.
- 7
Does anyone on the plan see a therapist or a psychiatrist, or want to?
Clients often leave this out of a list of doctors, then find their provider is out of network or that telehealth visits are covered differently. Asking it as a plain question, alongside everything else, makes it easier to answer than a mental health section would.
- 8
Who needs to be covered, and does anyone have another option through their own job or a parent?
Splitting a household across two plans is sometimes cheaper and sometimes a trap, and you cannot tell until you know what else is available. This is also where you find the adult child who could stay on a parent's plan and the spouse whose employer contribution nobody had checked.
- 9
Is anyone turning 26, turning 65, retiring, or leaving a job in the next twelve months?
Each of those creates a coverage change on a fixed date, and some open a special enrollment window. Finding out now avoids recommending a family plan that has to be rebuilt in four months.
- 10
What else do you expect to change this year: a baby, a move to another state, a surgery you have been putting off?
Clients treat plans as an annual decision and their lives as unpredictable, so ask about the predictable parts. A planned pregnancy or an out-of-state move affects network choice more than any benefit comparison will.
- 11
Roughly what do you expect the household to bring in this year, and how steady is it?
Marketplace assistance is based on projected income for the coming year, not last year's tax return, so a self-employed client with a variable income needs to understand that a good year can create a repayment at filing. Ask about the shape of the income, not just the figure.
- 12
What can you pay each month without having to think about it, and what number starts to hurt?
Two numbers are more useful than a budget, because the gap tells you how much room you have. Clients who name only one figure usually name the one they wish were true, and will drop the plan in April.
- 13
If a six thousand dollar bill arrived in March, where would that money come from?
This is the question that decides between a low premium with a high deductible and the reverse, and it is more honest than asking about risk tolerance. Savings, a credit card, or no answer at all are three different recommendations.
- 14
What did healthcare actually cost you last year, premiums and everything else added together?
Most people know their premium and nothing else. Adding up deductibles, copays, drugs and dental usually surprises them, and it gives you a real baseline instead of a premium comparison that hides where the money went.
- 15
Have you ever had a claim denied or a bill you were not expecting? What happened?
Tells you both their history and their tolerance. Someone burned by an out-of-network anesthesiologist or a prior authorization refusal will value predictability over price, and they need to hear how you would handle it next time.
- 16
How much time do you spend away from this area, and do you travel outside the country?
Snowbirds, remote workers and students at out-of-state colleges routinely end up with a plan that covers almost nothing where they actually live. Ask where they sleep for more than a month a year, not whether they travel.
- 17
Do you have an HSA or FSA now, and do you actually spend it?
An unused balance suggests the tax advantage is theoretical for this client, while a habitually drained FSA suggests real ongoing costs worth quantifying. It also tells you whether an HSA-qualified plan is a genuine option or just a talking point.
- 18
Which of dental, vision and hearing would you pay extra for, and which would you drop first?
Forcing a ranking gets a decision instead of polite interest in everything. A client with three crowns coming answers this very differently from one who has not seen a dentist in a decade, and the ranking is what you build the quote around.
- 19
When you compare two plans, what makes you pick one: the monthly premium, the deductible, or keeping your doctors?
You are asking for their decision rule so you can present options in those terms. If the stated rule contradicts what they told you earlier, say so now, gently, rather than discovering it when they reject your recommendation.
- 20
Who else is part of this decision, and by when does it need to be settled?
A spouse who has not been in the room can undo an hour of work, and an enrollment deadline determines how much of this can be done properly. Ask what the absent person is most likely to object to.
Running the discovery appointment
Practical guidance for the conversation itself.
How to sequence it
How to sequence it
Facts before money
Start with what they have, who is on it and what care they used. Clients answer the budget question more honestly once they have spent ten minutes remembering how much healthcare they actually consumed.
Ask for last year, not next year
Self-reported expectations of future use are close to useless. Visits, prescriptions and hospital stays from the last twelve months are the only reliable predictor a client can give you in a first meeting.
Write down names and doses
Doctor names, hospital, and drug names with dose. You cannot check a network or a formulary from a description, and getting this wrong is the mistake clients remember and repeat to other people.
Say what you will do with the answers
Explaining that income affects assistance, and that a drug list decides the formulary check, gets better information than asking the same questions cold. It also makes the income question feel like arithmetic rather than an intrusion.
What to verify before you present anything
What to verify before you present anything
- Check each named doctor and hospital against the plan's current directory, then confirm with the practice directly. Directories are frequently out of date and the client will blame the recommendation, not the carrier.
- Run every prescription through the plan's drug list and note the tier, any prior authorization, and whether the pharmacy they use is preferred.
- Confirm whether a scheduled procedure falls before or after the plan start date, and what happens to any deductible already met this year.
- Check that dependents living elsewhere, at college or with another parent, are inside the network area.
- Note the enrollment window that applies and whether any life event opens a special one.
Where these conversations go wrong
Where these conversations go wrong
Quoting before the fact-find is finished
A premium mentioned early becomes the anchor for everything after it, and every better-fitting plan then looks expensive. Hold the numbers until you have the doctors, the drugs and the two budget figures.
Letting the client self-diagnose as healthy
Healthy is a self-image, not a claims history. The visit count and the prescription list routinely contradict it, and the contradiction is easier to raise in the same breath as the question than later.
Guessing at assistance or tax treatment
Estimating a subsidy or the tax consequences of an HSA off the top of your head creates a number the client will hold you to. Give the rule, run the calculation properly, and refer tax questions to their preparer.
Explaining benefits in carrier language
Coinsurance, out-of-pocket maximum and formulary tier mean nothing to most clients. Translate each into what it costs them in a specific situation they have described to you.
Closing the meeting
Closing the meeting
- Read the constraints back as a list: these doctors, these drugs, this monthly figure, this deadline. Corrections almost always come at this point.
- Present two or three options with the tradeoff stated plainly, not a full menu. More than three shifts the work back onto the client and stalls the decision.
- Show what each option would have cost them against last year's actual use, which is the comparison they can check.
- Agree what happens if a claim is denied or a doctor leaves the network, and put your part of that in writing.
- Diarize the changes they told you about, the birthday, the retirement, the move, and contact them before the date rather than after it.