Getting health insurance can be overwhelming for beginners. Policies seem filled with confusing terms and options. But having coverage is essential for protecting your physical and financial wellbeing.
This comprehensive beginner’s guide covers everything you need to know about choosing, using and understanding health insurance.
Follow our tips to gain clarity and confidence on:
- Health insurance basics
- Types of plans
- Choosing coverage
- Using your benefits
- Managing costs
- Public health insurance programs
Let’s start with the fundamentals to build your insurance know-how.
Also, Check this as well Health Insurance FAQs
Health Insurance Basics
Health insurance helps pay for medical care like doctor visits, medications, tests and procedures. It protects you from unexpectedly high care costs.
Here are some key terms and concepts:
Premium– The amount you pay monthly or annually for coverage. Higher levels of coverage cost more.
Deductible – The amount you pay out-of-pocket before insurance kicks in. Often $1,000-$5,000 per year.
Copay – A fixed fee per visit or prescription once you meet the deductible, like $20 per doctor visit.
Coinsurance – The percentage you pay for care after reaching your deductible, like 20%.
Out-of-pocket maximum – The most you’ll pay annually before insurance covers 100% of costs. Often $5,000-$10,000.
Covered services – Health services and medications your insurance plan agrees to pay a part of.
Preventive care – Routine screenings and check-ups that are fully covered before the deductible.
Provider network – The doctors and hospitals your insurer contracts with at set fees. Using in-network providers costs you less.
Preauthorization – Approval from your insurer required for certain services before getting care.
Types of Health Insurance Plans
There are several main types of health insurance plans, each with pros and cons. Common options include:
Health Maintenance Organizations (HMOs)
How they work:
- Only use doctors in your insurer’s network except in emergencies
- Select a primary care doctor (PCP) who coordinates your care
- Get referrals from your PCP to see specialists
- Preauthorization is required before getting care
- More affordable monthly premiums
- Low or no deductibles
- Little paperwork since PCP coordinates everything
- Limited provider choice since you can only use network doctors
- Waiting periods to get referrals and preapprovals
Preferred Provider Organizations (PPOs)
How they work:
- Access a preferred network of doctors in your plan but can also use out-of-network providers at higher costs
- See specialists without needing referrals
- Preauthorization may be needed for certain procedures
- Freedom to use variety of providers
- Out-of-network care option
- No waiting for referrals to specialists
- Monthly premiums cost more than HMOs
- You pay more to use out-of-network providers
- Preauthorizations still required for some care
Point of Service (POS)
How they work:
- Combines aspects of PPO and HMO plans
- Assign a PCP to coordinate in-network care and referrals
- Has the option to self-refer to specialists for higher costs
- In-network costs like an HMO
- PCP guidance but can self-refer like a PPO
- Confusing mix of HMO and PPO rules
- Self-referral results in higher out-of-network costs
High-Deductible Health Plans (HDHPs)
How they work:
- Have very high deductibles, often $2,000-$10,000+ per year
- Once the deductible is met, costs are covered like a traditional plan
- Often paired with Health Savings Accounts (HSAs) for tax-free savings
- Much lower monthly premiums
- Can contribute to an HSA pre-tax
- Very expensive if you get sick or injured before meeting the astronomical deductible
Choosing the Right Health Insurance Plan
Choosing coverage involves balancing your budget, health, doctor preferences and lifestyle. Consider these factors:
Cost– Compare monthly premiums, deductibles, copays and maximum out-of-pocket costs across plans. Consider worst and best case scenarios.
Health needs – Know your medical conditions, medications and how often you use healthcare to estimate costs. More utilization needs lower deductibles.
Family – Insure any dependents like children or a non-working spouse. Consider maternity needs or pediatric care.
Providers – Make sure the doctors you want to see are in-network. Search provider directories.
Prescriptions – Check whether your medications are covered and at what tier cost.
Choice – Know if you want the freedom of a PPO or the coordination of an HMO.
Travel – Choose nationwide coverage if you travel frequently.
Tiered networks – Some plans divide providers into tiered networks. Tier 1 costs less than Tier 2 or 3.
Flexible spending – Know if you want to contribute to a Health Savings Account (HSA) or Flexible Spending Account (FSA).
Deductible fund – Have savings to cover the deductible in case of major illnesses or accidents.
Benefits – Carefully review what services and therapies are covered or limited.
Exclusions – Note key exclusions like vision, dental, fertility, long-term care, etc. You may need separate insurance.
To make the best choice, consult with both financial and medical professionals. Compare multiple plan options before deciding.
Using Your Health Insurance Plan
Once enrolled, learn how to maximize benefits and manage costs through smart utilization.
Pick a PCP – Primary care doctors coordinate HMO care. Even in PPOs they help guide referrals.
Get preventive care – Take advantage of 100% covered preventive visits, screenings and immunizations. Stay up to date.
Get preauthorizations – Contact your insurer to get required approvals before procedures, equipment, therapies and certain drugs. Confirm coverage.
Ask about costs – Request cost estimates from both your doctor and insurer to avoid surprise bills. Negotiate if needed.
Use in-network providers – Stay in-network whenever possible to limit out-of-pocket expenditures.
Consider urgent care – Use urgent care clinics to save money over emergency rooms for non-life-threatening needs.
Use generics – Choose generic prescriptions which are vastly cheaper than brand names. Check your formulary.
Review bills carefully – Ensure you are only paying the agreed upon in-network rates and not being overcharged. Dispute errors.
Negotiate payments – If struggling to pay, call providers to negotiate discounted rates or payment plans. Don’t ignore bills.
Meet deductibles – If you have upcoming care, strategize to meet deductibles in the same year either through major procedures or check-ups.
Appeal denied claims – If your insurer does not cover a service or medication, file an appeal explaining medical necessity.
Compare plan options annually – Upon renewal, compare other plans through the Marketplace or employer to see if switching makes sense.
Managing Health Insurance Costs
Use these tactics to get the most value from your plan without overspending:
Compare prescription prices – Shop around to pharmacies and use discount apps to get the cheapest prices on medications.
Use tax-advantaged accounts – Contribute to HSAs or FSAs to pay healthcare costs tax-free.
Automate payments – Set up auto-pay on healthcare bills and insurance premiums to ensure continuous coverage. Earn prepayment discounts.
Take care of yourself – Eat healthy, exercise, quit smoking and reduce risks to avoid needing expensive care.
Choose HDHPs – Get lower premiums with high deductible plans best for the young and healthy. Pair with HSAs.
Raise deductibles – Bump up deductibles to reduce monthly costs if you can afford to pay more out-of-pocket when sick.
Enroll in wellness programs – Participating in workplace or health plan fitness and wellness initiatives can lower premiums.
Make lifestyle tradeoffs – Look at housing, cars, vacations, etc. to balance life priorities vs healthcare costs.
Look into subsidies – Check if you qualify for lower-cost coverage through Medicaid, Medicare or the ACA Marketplace.
Shop around annually – Compare plans each year at open enrollment or if your situation changes to ensure appropriate affordable coverage.
Protect your credit – Keep up with premiums and doctor/hospital bills to avoid collections harming your score.
Public Health Insurance Programs
Those who can’t afford private health insurance may qualify for government-subsidized coverage:
Medicaid – Joint federal and state program providing free or low-cost coverage to qualifying lower-income individuals/families.
Medicare – Federal health insurance for seniors 65+ and those with certain disabilities. Includes Parts A, B, C and D.
ACA Marketplace plans – Individual insurance plans available with income-based subsidies through Healthcare.gov.
CHIP – Children’s Health Insurance Program for uninsured minors in families who earn too much for Medicaid but can’t afford coverage.
Veterans benefits – The VA health system offers coverage to qualifying veterans and service members.
COBRA – Temporary continued group health insurance after leaving a job. You pay the full premium cost.
Charity care – Some providers offer free or discounted care for financial hardship cases. Apply directly through hospital financial assistance programs.
Key Takeaways on Health Insurance Basics
- Have continuous, adequate coverage to protect yourself from financial ruin.
- Choose an affordable plan that fits your health needs, doctors, medications and budget.
- Use in-network providers and preventive care to maximize savings.
- Manage costs through smart utilization, wellness, and comparison shopping.
- Check if you qualify for public health programs like Medicaid, Medicare or ACA subsidies if needing assistance.
Frequently Asked Questions About Health Insurance
What types of health insurance are available?
Common types include HMO, PPO, POS, HDHP, government programs like Medicare and Medicaid, employer group plans, and Affordable Care Act marketplace plans.
What is covered by health insurance?
Covered services vary by plan but generally include doctor visits, hospitalization, emergency care, procedures/surgeries, preventive screenings, mental health services, prescriptions, and maternity care.
How do I pick a health insurance plan?
Compare costs, coverage, provider networks, prescription benefits, utilization needs, health status, subsidies, and supplemental insurance needs. Weigh pros and cons.
What if I’m unemployed, self-employed or retired?
Explore options like COBRA, individual marketplace plans (potentially subsidized), public programs if you qualify, coverage through a spouse, or short-term coverage until insured again.
What are the penalties for not having health insurance?
You may have to pay the full cost of any care needed. Not having minimum essential coverage may also incur a tax penalty depending on your state.
How do I use my health insurance?
Show your ID card at appointments, stay in-network, get preauthorizations for certain care, use preventive benefits, check explanations of benefits, and keep good records.
How can I save money on healthcare costs?
Use preventive care, know your costs, use generics, compare prescription prices, try telehealth, contribute to HSAs/FSAs, improve health, negotiate bills, and compare plans annually.
What if I lost my health insurance?
Look into COBRA, spousal plans, Medicaid if eligible, ACA marketplace plans, temporary coverage, student plans, or find a new employer plan quickly to avoid gaps.
What is covered under Medicare?
Medicare covers hospital, medical, and prescription drugs for seniors. Parts include Part A Hospital Coverage, Part B Medical Coverage (premium required), Part C Advantage Plans, and Part D Prescription Plans (premium required).
Can I get Medicaid if my income is too high?
Medicaid eligibility is based on strict income thresholds that vary by state. Some states expanded Medicaid further under the ACA. If your income exceeds the limits, explore subsidized marketplace plans.