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Health Insurance Basics
Health Insurance Cost
What Is a Health Insurance Deductible?
What Is an Out-of-Pocket Maximum?
Deductible vs Out-of-Pocket Maximum
What Is a Copay?
What Is Coinsurance?
Types of Health Insurance
What Is an Exclusive Provider Organization (EPO) Plan?
What Is a Health Maintenance Organization (HMO) Plan?
What Is a Preferred Provider Organization (PPO) Plan?
Health Insurance Coverage
Everything you wanted to know about how it works and where to get it.
Updated April 21, 2021|23 min read
Table of Contents
Health insurance is a product that covers your medical expenses. Like auto insurance covers your car if you get into an accident, health insurance covers you if you get sick or injured. Health insurance also covers preventive care – i.e., doctors visits and tests before you get sick.
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Health insurance doesn't always cover 100% of your costs. In fact, it's designed to split the costs of medical care with you up until a certain point, called the out-of-pocket limit. After you hit the out-of-pocket limit, health insurance will pay 100% of your health care costs and medical bills.
There are a few ways that health insurance companies might share costs with you, and they make up major features of your health insurance plan that you need to be aware of: your deductible, your copayment, your coinsurance, and your out-of-pocket limit. We'll discuss them in more detail in our "Key features" section below.
All health insurance plans need to cover the 10 essential benefits. In addition to the 10 essential benefits, health insurance plans must meet certain affordability standards, as well as other rules that vary on a state-by-state basis, in order to be included on a government-run health insurance exchange. Off-exchange plans, so called because they are not sold on government-run exchanges, must also cover the 10 essential benefits and meet certain federal standards in order to be considered qualifying health coverage. These consumer protections closed loopholes that caused financial problems for policyholders in the past.
Through 2018, as outlined in the Affordable Care Act (the ACA, also known as Obamacare), all American citizens needed to have qualifying health coverage, which was called the individual mandate. If they didn't, they had to pay a fee on their federal tax return.
As of 2019, the individual mandate has been suspended. There is no longer any penalty for not having health insurance. However, if you are filing back taxes for a tax year before 2019, you may still need to file Form 1095 to prove you had coverage.
Literally everyone should buy health insurance because medical expenses are simply too high to cover out of pocket. Medical bills are a leading cause of consumer debt and related financial problems (e.g., bankruptcy and home foreclosure).
If you’re buying health insurance and you fit into one of the following groups, we’ve listed a few additional considerations for when you’re shopping for health insurance.
You should also be aware that your plan may have a family deductible in addition to individual deductibles for each family member. Individual deductibles are lower than the family deductible. Once an individual hits their individual deductible, their health insurance plan kicks in just for them . But once the family deductible is met, health insurance kicks in for every member of the family , regardless of whether or not an individual has reached their deductible.
You can stay on a parent’s health insurance plan until you’re 26 years old, so no need to buy health insurance if your parents are willing to let you stay on their plan. You can also check your university for health insurance plans, which may be more affordable. This is an especially good option if you’re going to college out of state, as your parent’s plan’s network may not work in your state.
If you just became self-employed after leaving a full-time W-2 job, you can use COBRA to continue your previous employer's coverage until you're able to find a new plan. If it's not open enrollment, you should also be able to qualify for a special enrollment period to shop on the marketplace.
Make sure your premiums are affordable, as your monthly income may be variable. Your health insurance premiums are also tax-deductible sometimes, so don't forget that come tax time.
Learn more about health insurance for freelancers.
People on a low income or tight budget should look into whether or not they qualify for Medicaid. Medicaid is a public health insurance plan available for low income individuals and families. We discuss Medicaid in more detail later.
If your income is between 100% and 400% of the federal poverty line, you likely qualify for a subsidy from the health insurance marketplace. This subsidy can help make health insurance more affordable.
The most important thing to remember is to have some sort of coverage in place. A serious health issue can turn into a financial disaster if you’re not careful. If you qualify, you could look into catastrophic plans; these low cost plans can protect you from the cost of serious illnesses and accidents but aren't available to everyone.
If you’re a veteran, you may qualify for health care through the U.S. Department of Veterans Affairs (VA). The Affordable Care Act does not change VA health benefits.
If you have health insurance coverage through a private-sector employer, you can have and use both health insurance plans at the same time.
All health insurance plans that count as qualifying health insurance cover pregnancy and childbirth related services. Maternity care and childbirth are one of the 10 essential benefits required on qualifying health plans under the ACA. These services are covered even if you became pregnant before your coverage starts. (For most health insurance plans, you can find the specific way your plan covers childbirth on page 7 of your Summary of Benefits and Coverage document.)
Having a child counts as a qualifying event for a special enrollment period in which you can enroll in a new plan or switch plans. (In the state of New York, becoming pregnant also qualifies you for a special enrollment period.)
Maternity care and childbirth are also covered by Medicaid and CHIP. If you qualify for Medicaid and CHIP and are pregnant, you can apply at any time during the year through your state agency or marketplace.
If you’re above the age of 65, you qualify for Medicare. We go into more detail into Medicare below, but the gist of it is that it’s a federal program designed to help you cover health care costs into old age.
You can also purchase supplemental insurance, called Medigap, that can help pay for your deductibles, copayments, and coinsurance. Medigap plans may or may not make sense for you – make sure you know what you’re buying before you start to pay for it.
If you’re an active duty service member, your health care (and your family’s health care) is covered by TRICARE. You do not need to purchase additional health insurance to comply with the ACA.
If you're married but don't have kids, you don't need to buy health insurance as a family. You can buy individual plans from separate companies, if that makes sense for you and your spouse. You can also purchase a family plan from the marketplace.
One of you can also be a dependent on the other's employer-provided health insurance plan, if that's available.
Generally, there are two types of health insurance: public health insurance (like Medicaid, Medicare, and CHIP) and private health insurance. Most people have some form of private health insurance, whether they purchase it through a marketplace or get it from an employer. State exchanges and the federal exchange can offer consumers both public health insurance and private health insurance.
On-exchange private health insurance policies are plans that are sold on government-run exchanges, like a state exchange or healthcare.gov, the federal exchange. On-exchange plans must cover the 10 essential benefits, plus any additional services that are mandated by your state government.
Additionally, any insurer that wants to participate in a government-run exchange must offer a plan at every metal tier (which we'll discuss in more detail later). On-exchange private plans are the only plans for which premium tax credits and cost-sharing reductions (i.e., government subsidies for qualifying applicants) are available.
Off-exchange private health insurance policies are plans that are sold either directly by the health insurance company, through a third-party broker, or a privately-run health insurance marketplace. Off-exchange plans must cover the 10 essential benefits and follow other rules dictated by the Affordable Care Act — meaning you don't have to worry about any loopholes or "gotchas" with off-exchange plans.
The caveat with off-exchange plans is that you typically can’t apply any subsidies (e.g., the premium tax credit or cost-sharing reductions) to these plans. (If you qualify for a subsidy, you might be redirected to your state exchange or healthcare.gov.) Providing an off-exchange plan may allow an insurer more flexibility. For example, because they don't have to offer a plan at every metal tier, insurers can offer just one type of health insurance plan.
Ultimately, if you're shopping for private health insurance, and you're ineligible for a premium tax credit, looking at off-exchange plans gives you more options at potentially lower price points.
Employer-provided health insurance plans, also called group plans , are private plans purchased and managed by your employer. Employer-provided plans need to follow the same rules as other private insurance plans and cover the 10 essential benefits.
Because group health insurance covers a large pool of people, it's generally much more affordable than a comparable individual plan. Typically, group plans have much lower premiums and deductibles.
If you're eligible for an employer-provided plan, you do not need to purchase additional coverage through the marketplace . Talk to your human resources department for more specific information about your plan.
Short-term health insurance plans provide limited health care coverage for a temporary gap in coverage. However, it's very important to note that short-term plans do not count as qualifying health coverage, and may not provide you with all the coverage you need.
Short-term health insurance may still be worth it to cover a short coverage gap of one or two months — for example, if you looking for a new job or a new job has a waiting period before your health insurance kicks in. Many large health insurers offer short-term options.
But be aware that short-term health insurance may have limits that regular health insurance does not have, such as caps on annual benefits paid.
Medicare is a federal health insurance program for Americans above the age of 65. It provides free or heavily cost-reduced health care to eligible enrollees.
There are four parts to Medicare that cover different health care services:
Part A for inpatient (hospital) care, for which most people pay no premiums
Part B, for outpatient care, like doctor's office visits. In 2021, Part B has a monthly premium of $148.50.
Part C, which is also called Medicare Advantage, and allows you to buy into private health insurance.
Part D, for prescription drug coverage.
If you're above the age of 65, you can apply for Medicare through healthcare.gov or your state exchange.
Medicaid is a federal and state health insurance program for low-income families and individuals. Medicaid has eligibility requirements that are set on a state-by-state basis, but it is primarily designed for those with low incomes and low liquid assets. It is also designed to help families and caretakers of small children in need. You can typically check if you qualify for Medicaid through healthcare.gov or your state exchange.
The Children's Health Insurance Program (CHIP) is a federal and state program that is similar to Medicaid, but specifically designed to cover children below the age of 18. The program is primarily aimed at children in families who have incomes too high to qualify for Medicaid but too low to afford private health insurance. Like Medicaid, you can typically see if you qualify and apply on Healthcare.gov or your state's exchange.
All private health insurance plans, whether they're on-exchange or off-exchange, work by partnering with networks of health care providers. But the way that these plans work with the networks can vary significantly, and you want to make sure you understand the differences between these plans.
HMO plans are the most restrictive type of plan when it comes to accessing your network of providers. If you have an HMO plan, you'll be asked to choose a primary care physician (PCP) that is in-network. All of your care will be coordinated by your PCP, and you'll need a referral from your PCP to see a specialist. HMOs do not cover any out-of-network health care costs.
HMO plans typically have cheaper premiums than other types of private health insurance plans.
PPO plans are the least restrictive type of plan when it comes to accessing your network of providers and getting care from outside the plan's network. Typically, you have the option between choosing between an in-network doctor, who can you see at a lower cost, or an out-of-network doctor at a higher cost. You don’t need a referral to see a specialist, though you may still choose a primary care physician. (Some states may require that you have a primary care physician).
PPO plans typically have more expensive premiums than other types of private health insurance plans.
EPO plans are a mix between HMO plans and PPO plans. EPO plans give you the option of seeing a specialist without a referral. However, EPO plans do not cover out-of-network physicians.
EPO plans typically have more expensive premiums than HMOs, but less expensive premiums than PPOs.
POS plans are another hybrid of HMO and PPO plans. You'll have a primary care provider on an HMO-style network that can coordinate your care. You'll also have access to a PPO-style network with out-of-network options (albeit at a higher cost). The HMO network will be more affordable, and you will need to get a referral to see HMO specialists.
POS plans typically have more expensive premiums than pure HMOs, but less expensive premiums than PPOs.
Learn more about the differences between HMOs, PPOs, EPOs, and POS plans.
Remember earlier when we talked about how all health insurance plans split some of the costs between the insurer and the consumer? Metal tiers are a quick way to categorize plans based on what that split is.
Some people get confused because they think metal tiers describe the quality of the plan or the quality of the service they'll receive, which isn't true.
Here's how health insurance plans roughly split the costs, organized by metal tier:
Bronze - 40% consumer / 60% insurer
Silver - 30% consumer / 70% insurer
Gold - 20% consumer / 80% insurer
Platinum - 10% consumer / 90% insurer
These are high-level numbers across the entirety of the plan, taking into account the deductible, coinsurance, and copayments, as dictated by the specific structure of the plan, based on the expected average use of the plan. These percentages do not take premiums into account. They also do not represent the exact amount that you'll actually pay for medical services.
In general, Bronze plans have the lowest monthly premiums and Platinum plans have the highest, with Silver and Gold occupying the price points in between. As you can see from the cost-sharing split above, Bronze plan premiums are cheaper because the consumer pays more out of pocket for health care services. If you frequently utilize health care services, you'll probably end up paying more out-of-pocket if you choose a Bronze plan, even though it has a lower premium.
If you qualify, you can use a health insurance premium subsidy to help you afford a plan in a higher tier, ultimately saving you money.
There's a fifth category of health insurance plans that you may see on the marketplace, called "catastrophic" plans. Catastrophic plans have very high deductibles — often, the deductible is the same as the out-of-pocket max — which means they're really only useful for preventing an accident or serious illness from causing you to go into severe debt. Catastrophic plans are only available for people under 30 or people with a hardship exemption. You cannot use a subsidy on catastrophic plan premiums, but, for years during which the health insurance mandate was active, catastrophic plans did count as qualifying health care.
When you shop for a health insurance plan, it's important to know what the key features are that decide how much you're actually going to pay for health care. These out-of-pocket expenses can be boiled down into five major features of your health insurance plan:
It's easy to think of your premium as your monthly bill. Every month, you pay a premium to a health insurance company in order to access a health insurance plan. As we'll get into in a second, while your monthly premium may be how much you pay for health insurance, it's not equivalent to how much you pay on health care services. In fact, choosing a plan with lower premiums will likely mean that you'll pay more out-of-pocket if you need to see a doctor.
A deductible is how much you need to pay for health care services out-of-pocket before your health insurance kicks in. In most plans, once you pay your deductible, you'll still need to pay copays and coinsurance until you hit the out-of-pocket max, after which the plan pays for 100% of services. Plans with lower premiums tend to have higher deductibles.
Note that the deductible and out-of-pocket maximum describe two different concepts: the deductible is how much you'll pay for a covered procedure before your insurance starts to pay, and the out-of-pocket maximum is the total amount you'll pay for care including the deductible.
A copayment, often shortened to just "copay," is a fixed amount that you pay for a specific service or prescription medication. Copayments are one of the ways that health insurers will split costs with you after you hit your deductible. In addition to that, you may have copayments on specific services before you hit your deductible. For example, many health insurance plans will have copayments for doctor's visits and prescription drugs before you hit your deductible. You will pay copayments until you hit your maximum out-of-pocket amount.
Coinsurance is another way that health insurers will split costs with you. Unlike a copayment, coinsurance isn't a fixed cost — it's a percentage of the cost that you pay for covered services. For example, if you have a coinsurance of 20%, you'll pay 20% of the cost of covered services until you reach your out-of-pocket maximum.
The maximum out-of-pocket amount, also called the out-of-pocket limit, is the most you'd ever have to pay for covered health care services in a year. Payments made towards your deductible, as well as any copayments and coinsurance payments, go toward your out-of-pocket limit. Monthly premiums don’t count.
The maximum out-of-pocket limit for 2021 is $8,550 for individual plans and $17,100 for family plans ; plans with higher premiums tend to have lower out-of-pocket limits. (The 2020 out-of-pocket limits were $8,150 for an individual plan and $16,300 for a family plan.)
Note that the maximum out-of-pocket is a consumer protection enacted under the ACA; previously plans didn't have to cap what a person would be required to spend on health care services. This often meant that insured people who had to undergo very expensive treatments (e.g., for cancer or life saving surgery) could face unlimited medical bills.
Health insurance doesn't always cover every aspect of your physical health, or your health-related costs, which is why you can buy supplemental health insurance products along with your health insurance plan. Some of these, such as dental and vision, may already be familiar to you.
Dental insurance is an insurance product designed to help you pay for dental care. Many dental plans are structured similarly to health insurance plans: there are dental HMOs and PPOs, for example. Dental plans are relatively inexpensive — even the most robust plans on the marketplace tap out at around $30 per month for an individual.
For more information about dental insurance and how it compares to dental discount plans, check out our guide. Note that dental insurance is typically included in health insurance plans for children under the age of 18.
Vision insurance is, you know, for your eyes. It's designed to help people pay the costs of regular eye exams, eyeglasses, and contact lenses. Major eye surgeries that are medically necessary, such as cataract surgery, are usually covered by health insurance plans.
Elective vision-corrective surgery may be covered by a vision insurance plan. Vision insurance plans usually cost around the same as dental insurance plans. Note that vision insurance is typically included in health insurance plans for children under the age of 18.
Gap insurance is a supplemental health insurance policy that helps you pay for out-of-pocket costs associated with your health care expenses. Designed to cover the "gap" in coverage left by plans with high deductibles, gap insurance can help you reduce your out-of-pocket expenses.
Gap insurance plans are not regulated by the Affordable Care Act, and do not offer the same consumer protections as qualifying health coverage
Critical illness insurance is a type of insurance product that helps you pay for expensive illnesses that impact you and your ability to earn money for multiple years. For example, Alzheimer's disease, cancer, and stroke are three diseases that a critical illness insurance policy may cover. Each critical illness policy has its own list of illnesses that it will cover.
If you are diagnosed with one of these illnesses while you're a policyholder, your insurer will typically pay you a lump sum cash payment. If you own a term life insurance policy, you can also get a critical illness rider attached to your life insurance policy for less money than a separate critical illness plan.
The Affordable Care Act, also known as Obamacare, made covering certain health care services a requirement for all health insurance plans available to consumers. These required services are known as the 10 health essential benefits. These 10 categories of services are:
Ambulatory patient services (outpatient care that you can receive without being admitted to a hospital)
Hospitalization for surgery, overnight stays, and other conditions
Pregnancy, maternity, and newborn care
Mental health and substance use disorder services
Rehabilitative and habilitative services and devices (treatment and devices that help people gain or recover mental and physical skills after an injury, disability, or onset of a chronic condition)
Preventive and wellness services, as well as chronic disease management
Pediatric services, including dental and vision coverage for children
Note that these are categories of services, and that the specific services offered within these categories may differ from state to state. Typically states require that plans offer more services to their customers, rather than restricting services you would expect to find under these categories. State, federal, and private exchanges will show you exactly which services each plan covers before you apply.
One thing private health insurance is not required to cover is durable medical equipment (DME), such as wheelchairs and ventilators. Because many people rely on this life-saving devices, be sure to get a health insurance plan that offers coverage for DME.
All health insurance plans on government-run marketplaces offer a set of preventative health care services, such as shots and screening tests, at no cost to plan members (even if you haven't hit your deductible). As of 2021, these are the 21 free preventive services, as outlined by Healthcare.gov:
Abdominal aortic aneurysm one-time screening
Alcohol misuse screening and counseling
Aspirin use to prevent cardiovascular disease
Blood pressure screening
Colorectal cancer screening
Diabetes (Type 2) screening
Falls prevention (for adults age 65 or older)
Hepatitis B screening
Hepatitis C screening
Lung cancer screening (for adults age 55 to 80 who are at high risk)
Obesity screening and counseling
Sexually transmitted infection prevention counseling
Statin preventive medication (for adults age 40 to 75 who are at high risk)
Tobacco use screening and cessation interventions
Tuberculosis screening (for certain adults at high risk)
Note that some of these screenings may only be for specific age groups. Look at your plan or talk to your insurer to check which preventative services are free for you. Women and children have their own set of preventive care benefits.
Thanks to the Affordable Care Act, there are only five factors that go into setting your premium:
Whether or not you use tobacco
Individual v.s. a family plan
Your plan category (Bronze, Silver, Gold, Platinum, or Catastrophic)
Health insurance companies are not allowed to take your gender or your current or past health history into account when setting your premium.
Health insurance premiums on the Affordable Care Act's marketplaces have increased steadily due to many different circumstances, including political uncertainty as well as the cost of doing business. Additionally, while average premiums for the benchmark second-lowest-cost Silver plan have fallen slightly since 2018, costs vary widely by state and insurance market.
Over 9 million people — or 84% — who got health care through marketplaces received tax credit subsidies in 2020, further reducing the actual cost of health insurance.
When it comes to figuring the cost of health insurance, however, you need to look at more than just the monthly premium. As we mentioned in the sections above, health insurance is only one part of your total spending on health care services. In fact, if you frequently visit a doctor and you buy a plan with a high deductible and low monthly premium, it's likely that you'll spend more money overall than if you bought a plan with higher premiums, a lower deductible, and lower copayments and coinsurance payments.
A premium tax credit may help you afford the right health insurance plan for you. A premium tax credit is a tax credit that you can apply in advance of your tax return in order to reduce the cost of your monthly premiums. You can also take the tax credit when you file your yearly tax return. Tax credits are only available to individuals and families within a certain income range — between 100% and 400% of the federal poverty line in your state.
Premium tax credits are only available on marketplace plans and cannot be used on public health insurance plans, catastrophic health insurance plans, or off-exchange private health insurance plans.
Generally, there is only one period of time in which you are allowed to apply for Obamacare marketplace. This is called the open enrollment period. You cannot purchase a health insurance plan outside of the open enrollment period unless you start a new job and get group health insurance, or if you qualify for a special enrollment period.
These enrollment periods are a relic of the individual health insurance mandate. Because health insurance companies must cover people regardless of preexisting conditions, the Affordable Care Act mandated that everyone buys health insurance, even if they believe they are healthy or do not need health insurance. Premiums from healthier customers who don't use a lot of health care services help offset the cost of covering people who do need to use more health services. Whether this continues after the suspension of the individual mandate remains to be seen.
Federal open enrollment for 2021 started on Nov. 1, 2020, and ended on Dec. 15, 2020. Some state-run exchanges extended their deadlines. You can find a state-by-state guide to Obamacare open enrollment here. The next open enrollment period will begin on Nov. 1 2021 for 2022 health coverage.
For people on non-group health plans, if you don't buy health insurance before your state's deadline, you will not be able to purchase health insurance for 2021 unless you qualify for a special enrollment period later in the year.
Before 2019, if you didn't have health insurance for more than two months out of the year, you had to pay a penalty for every month that you went without coverage. This penalty was calculated on your tax return for the respective year. Since the suspension of the individual mandate tax penalty, you no longer need to have health insurance.
A special enrollment period begins with a qualifying event. Qualifying events literally qualify you for a special enrollment period; some examples of qualifying events include turning 26, getting married, and having a baby. Moving to a new zip code also qualifies you for a special enrollment period. Some states may have their own additional qualifying events. You do not qualify for a special enrollment period if you fail to pay your premiums and your coverage lapses.
To check if you qualify for a special enrollment period, fill out the form on your state, federal, or private marketplace.
Finding a health insurance plan that fits you and your needs doesn't have to be a pain. When shopping for an affordable health insurance plan, it's important to know what makes a plan affordable to you, specifically. Do you rarely utilize health care services? A high deductible, low premium plan probably makes sense for you. Are you managing a chronic illness? A health insurance plan that has higher premiums, but has lower out-of-pocket costs, will probably be more affordable in the long run.
Learn more in this guide on how to get affordable health insurance.