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What is health insurance and why do I need it?

• Everyone deserves affordable high-quality health coverage and care regardless of the individual qualities that make us who we are, like our race, gender, disability, or health status.

  Health insurance providers are working to improve health equity by addressing health care disparities; removing social barriers to good health; and promoting diversity, equity and inclusion.

• Health insurance – also referred to as medical insurance or healthcare insurance – refers to insurance that covers a portion of the cost of a policyholder’s medical costs.

  How much the insurance covers – and how much the policyholder pays via copays, deductibles, and coinsurance – depends on the details of the policy itself, with specific rules and regulations that apply to some plans.

• If you don’t have health insurance and you end up needing medical care, you can be left with insurmountable medical bills or even face situations in which medical providers refuse to treat you. Only screening and stabilization in a hospital emergency department are guaranteed if you’re uninsured.

  Other than that, it’s up to the provider to decide whether to treat you if your ability to pay for the care is in question. Even if your out-of-pocket costs seem high under the health plans available to you, having a health insurance card might make the difference between being able to obtain care or not.

• It’s also important to understand that you cannot just purchase health insurance when a medical need arises. Regardless of whether you’re buying your own coverage or enrolling in a plan offered by an employer, there’s an annual open enrollment period that applies, and enrollment outside of that window is limited to .

• Having health insurance provides a safety net in case you end up with a serious injury or illness: All non- major medical health insurance plans will cap your in-network out-of-pocket costs (a combination of copays, deductibles, and coinsurance) at no more than an amount determined by CMS each year, regardless of how high your medical bills actually get. For 2021, it’s $8,550 for a single person; $17,100 for a family, although many plans have lower limits.

• Health insurance also helps with smaller expenses in the form of free preventive care (required on all non-grandfathered major medical plans; the enrollee does not have to pay a deductible, copay, or coinsurance for a service that falls within the list of recommended preventive care) and, depending on the plan, copays for things like office visits and prescription drugs. (If the plan has copays, it generally means you pay a certain amount for those services and the health insurance plan pays the rest of the costs, even if you haven’t met your deductible yet.)

• Thanks to the Affordable Care Act (Obamacare), all non-grandfathered, non-grandmothered individual and small-group major medical plans include coverage for the types of care that are considered essential health benefits under the ACA, without any maximum cap on how much the insurance plan will pay for your care. (Large-group plans and self-insured plans are governed differently; they are not required to cover essential health benefits – although most of them do – but for any service they do cover that falls within an essential health benefit category, they cannot impose lifetime or annual benefit maximums).

  What are the different types of health insurance?

  There are several different types of health insurance in the U.S., including public coverage (Medicare, governed by the federal government, Medicaid and CHIP, governed by both the federal government and state governments, Indian Health Services, VA coverage) and private coverage.

• Private healthcare coverage can be provided by an employer (group insurance, including both large-group and small-group plans) or purchased in the individual/family market. Members of the armed services and their families are covered under Tricare, and people employed by the federal government are covered under FEHB.

• Both public and private plans tend to use a managed care model (HMO, PPO, EPO, or POS plan, or sometimes a hybrid model), in which a private insurer will manage and oversee the provision of services, the quality of the care provided, the reimbursement system, the provider network, and rules such as prior authorization or step therapy.

• In the individual family market, all major medical healthcare plans with effective dates of January 2014 or later are governed by the Affordable Care Act and required to be compliant with its provisions, regardless of whether they’re sold in the exchange or. These plans all offer coverage on a guaranteed-issue basis, regardless of an applicant’s medical history. But coverage is only available during open enrollment or a special enrollment period triggered by a qualifying event.

• There are still grandmothered and grandfathered plans in effect in the individual and small-group markets in many states (and grandfathered plans in the large-group market), but these plans have not been able to enroll new members – except for new family members or new employees on existing employer-sponsored plans – since 2013 or 2010, respectively.

• There are also a variety of non-ACA-compliant healthcare plans available, although most of them are better suited to be supplemental coverage rather than stand-alone coverage. (For example, direct primary care plans and fixed-indemnity plans are not suitable to serve as a person’s only coverage). Short-term health insurance, which is available in most states, is designed to be stand-alone coverage, but only for a short period of time, and with the understanding that it can have significant gaps in the coverage.

How do consumers buy health insurance coverage?

If you don’t have access to coverage provided by an employer, you’ll need to obtain your own health insurance in the market for individuals and families. You can visit to see the options that are available to you and how much the monthly premiums would be.

If you’re not eligible for premium subsidies (premium tax credits) or cost-sharing reductions (a subsidy that reduces your out-of-pocket costs, including deductible and coinsurance), you might want to also check with a broker to see if there are additional plans available outside the exchange in your area.

(You can only apply premium tax credits to plans purchased in the exchange, and you can only get cost-sharing reductions if you buy a silver plan through the exchange; you can use this calculator to see whether you’ll be eligible for a premium tax credit.)

If you feel that you can confidently manage your own enrollment and health coverage, you can enroll on your own. But the services of brokers and enrollment assisters are available free of charge, and they can help you manage the process.

Depending on your income and where you live, your state may provide you with Medicaid coverage. If you’re eligible, your state’s marketplace will direct you to the application portal for Medicaid, and there are people available in your state who can help you complete the enrollment and answer any questions you may have.

If you’re eligible for Medicare and don’t have supplemental coverage provided by a current or former employer, you’ll also likely need to seek out supplemental coverage on your own, via Medicare Advantage or Medigap plus Medicare Part D.

Health insurance , complete with their unique features and benefits, will help you evaluate your options and guide you when registering for a plan. The type of health insurance you choose will determine the cost and quality of medical care that you receive.

Let’s take a closer look at the different types of health insurance and their advantages and disadvantages to help you choose what’s best for you.

A preferred provider organization is one of the most common managed care health insurance options. This type of insurance offers you the ability to receive medical care from a preferred network of health providers without a referral. With a PPO, you get to choose your healthcare provider from the insurance company’s network. However, you can also avail yourself of the services of out-of-network providers, but at higher costs.

PPO health insurance pros

• Flexibility – A PPO allows you to visit any physician, both in-network and out-of-network. This gives you the flexibility of getting the quality of services you need if they are not available within the insurance company’s network. You don’t have to choose a primary care provider (PCP) and, therefore, don’t require referrals when seeking services from specialists. This takes a lot of the time and hassle out of your medical care.
• Wide Coverage – Since PPOs allow for both in-network and out-of-network healthcare, you get a wide array of medical providers to choose from. PPO health insurance also covers many different medical procedures from check-up and prescription medicine to outpatient surgery. Some plans even cover alternative treatments like therapeutic massage and acupuncture.

PPO health insurance cons

• High Costs – PPOs are ideal for you if you are comfortable paying more to enjoy the flexibility not offered by other types of health insurance. Co-payments of about $10 to $20 are common but can stack up quite quickly, and you may not enjoy coverage before meeting the annual deductible requirement. Also, out-of-network services cost more, and you will frequently end up paying a larger percentage of the bill.
• Filing for claims – While you may not need to file your claim when using in-network providers, the opposite is true for out-of-network medical care. You will be solely responsible for all the paperwork in filing your claims, which can be a complex affair.

Health Maintenance Organization health insurance (HMO)

A health maintenance organization requires members to only use a specific network of providers. You have to choose a primary care physician (PCP) and obtain a referral from your PCP before seeing a specialist. Usually, you will only be covered for the services you get from in-network providers unless you are authorized to use outside services.

HMO health insurance pros

• Less Costly – Since you are only restricted to a specific network of health providers, you incur low out-of-pocket costs as well as premiums. This is because health care providers contract with insurance companies to provide medical services at low rates, and some plans don’t even have deductibles.
• No Paperwork – The healthcare providers handle your claims, lifting the burden off of your shoulders.

HMO health insurance cons

• Requires Referral – With an HMO insurance, you will need to obtain a referral from your PCP before you can see a specialist or physician. This wastes time when you know that you need the services of a specialist and still have to jump through hoops to get there.
• Highly Restrictive – HMO health insurance doesn’t cover out-of-network medical services, limiting you to the physicians within the network. If you decide to get treatment outside the network, you will be responsible for all the costs. You should get approval for any treatment outside the network, and, in case of emergencies, you need to notify your provider so you can obtain follow-up care from in-network facilities.

Point of Service health insurance (POS)

Point of service health insurance combines the features of both HMO and PPO plans. As with a PPO, you have the option of going out of network, but you will have to incur higher deductibles. You also have to choose a primary care physician and obtain referrals like you would with HMO insurance.

POS health insurance pros

• Cheaper than PPOs – For in-network medical care, there are no deductibles, and the co-payments are low (between $10 and $20). This means that out-of-pocket costs are significantly reduced. While the cost breakdown is just like other types of health insurance, POS will cost you less than a PPO.
• Flexible Coverage – POS has no local restrictions when it comes to coverage benefits, and you can use it while traveling. You also have the option of going out-of-network, albeit at a higher cost, which gives you wide access to health providers.

POS health insurance cons

• Referrals Required – Just like an HMO, you will need a referral from your PCP before seeing specialists, which can be time-consuming. Without a referral, you may either be partially covered by your insurance or not at all.
• Paperwork – You should be prepared to personally file your claims for out-of-network treatment. This means you have to pay upfront, then handle all the paperwork and procedures that come with seeking reimbursement.

Exclusive Provider Organization health insurance (EPO)

Exclusive provider organizations have a network of healthcare providers that members are supposed to stick to. Treatment outside of the network is not covered by the insurance plan, and you don’t need a referral to see a specialist. It is more of a PPO without the out-of-network option. It may be subject to deductibles and small co-payments from members.

EPO health insurance pros

• Reduced Costs – Insurance companies can negotiate for lower healthcare costs as they are sure that members will only visit the given medical care providers. Also, EPOs pay for services provided and are not based on monthly payment schedules.
• No Referrals – You don’t need to obtain referrals from your PCP in order to visit any specialist within the network. This gives you the freedom that isn’t available with HMO insurance.

EPO health insurance cons

• Small Network – Unlike HMOs and PPOs, EPOs have a smaller network of healthcare providers in given locations. This leaves you with fewer options when it comes to where you can get medical care.
• No Out-of-Network Services – EPOs are not suitable for people who may require ongoing services from specialists outside the network. You will have to incur the costs personally as it restricts members to in-network physicians.

Indemnity health insurance

Indemnity health insurance is also known as a fee-for-service plan. It doesn’t have a network of healthcare providers, and members are reimbursed a percentage of their medical costs for covered services. Indemnity health insurance focuses on treatments, and you are responsible for deductibles and co-insurance payments.

Indemnity health insurance pros

• Freedom – You are not limited to a given network of healthcare providers, and you can choose whatever medical facility or physician you prefer. There are also no PCPs involved and therefore nor referrals. This type of insurance gives you a lot of control over your healthcare.

Indemnity health insurance cons

• Lots of Paperwork – In most cases, you will first pay for medical services then file for claims in order to be reimbursed, which can be a headache.
• High Cost – There is usually no agreement between insurance companies and healthcare providers to offer services at given rates. This may lead to higher costs, which may fall to you if they surpass the limits considered customary and reasonable by the insurance.

Health Insurance Conclusion

The good news is that there are lots of choices, and the bad news is—you guessed it—there are lots of choices. As you embark on this decision, make a list of your healthcare priorities.  What matters most to you?  Physician choice?  Convenience?  Low cost? There are benefits and drawbacks to most every plan, so decide what you can and can’t do without, and make your decision accordingly.

Insurance serves as a guarantee to ensure that whatever happens to you, bills, hospitalization, and any other privileges can ease the burden that you are feeling. Find the type of insurance that will help you best. Any of these insurances provide advantages but there are also some consequences for choosing one.

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