Health Insurance Information Center

Health insurance is a contract between you and an insurance company where you pay monthly premiums in exchange for coverage of medical expenses. It helps protect you from high medical costs by covering services like doctor visits, hospital stays, prescription drugs, and preventive care.

HMO (Health Maintenance Organization) requires you to choose a primary care physician and get referrals for specialists, but typically costs less. PPO (Preferred Provider Organization) offers more flexibility to see any doctor without referrals but costs more. EPO (Exclusive Provider Organization) is a middle ground - no referrals needed but you must stay in-network except for emergencies.

A deductible is the amount you pay out-of-pocket before your insurance starts covering costs. For example, with a $2,000 deductible, you pay the first $2,000 of medical expenses yourself. After that, your insurance begins to pay according to your plan's coverage terms.

A copay is a fixed amount you pay for specific services (like $25 for a doctor visit). Coinsurance is a percentage of costs you pay after meeting your deductible (like 20% of the bill). These are your share of costs even after insurance kicks in.

Consider your budget, health needs, preferred doctors, and prescription medications. Look at the total cost (premiums + out-of-pocket expenses), check if your doctors are in-network, ensure your medications are covered, and consider whether you want more flexibility (PPO) or lower costs (HMO).

Check if your medications are on the plan's formulary (covered drug list), what tier they're in (affects cost), and if there are any restrictions like prior authorization or step therapy. Also consider the plan's pharmacy network and mail-order options for ongoing medications.

Very important! Using in-network providers costs significantly less than out-of-network ones. Make sure your current doctors, preferred hospitals, and specialists are in the plan's network. If you travel frequently, consider plans with broader networks.

The out-of-pocket maximum is the most you'll pay in a year for covered services. Once you reach this amount, your insurance pays 100% of covered costs for the rest of the year. This includes deductibles, copays, and coinsurance, but not premiums.

Budget for monthly premiums, deductibles, copays, coinsurance, and any out-of-network costs. Consider your expected healthcare usage - if you rarely see doctors, a higher deductible plan might save money. If you have ongoing health needs, lower deductibles might be better despite higher premiums.

Preventive care includes services like annual checkups, screenings, and vaccinations designed to prevent illness or detect problems early. Most health plans are required to cover preventive care at 100% with no deductible, copay, or coinsurance when you use in-network providers.

Common exclusions include cosmetic surgery, experimental treatments, some alternative medicine, and services deemed not medically necessary. Coverage varies by plan, so review your policy documents for specific exclusions and limitations.

Out-of-network care typically costs more - you may pay higher deductibles, coinsurance, or the full cost of services. Some plans don't cover out-of-network care at all except for emergencies. Always check with your insurance before seeing out-of-network providers.

You can enroll during Open Enrollment (typically November-December), when you have a Qualifying Life Event (job loss, marriage, birth of child), or when you first become eligible (new job, aging out of parent's plan). Some plans may have different enrollment periods.

Generally, you can only change plans during Open Enrollment or if you have a Qualifying Life Event. However, you typically have 30-60 days to make changes after a qualifying event. Some employer plans may allow changes during their annual enrollment period.

Missing the deadline means you may have to wait until the next Open Enrollment period unless you qualify for a Special Enrollment Period due to a life event. You might face a penalty for being uninsured, depending on your state's requirements.

Coverage typically starts on the first day of the month after you enroll and pay your first premium. If you enroll by the 15th of the month, coverage may start the first of the next month. If you enroll after the 15th, it may start the first of the following month.

Present your insurance card when receiving care. For HMO plans, typically get care from your primary care physician first, who can refer you to specialists if needed. For PPO/EPO plans, you can often see specialists directly. Always verify providers are in-network before receiving care.

Review the denial reason, check if the service is covered under your plan, ensure you followed plan rules (like getting referrals), and verify the provider is in-network. You can appeal the decision by contacting your insurance company and providing additional information or documentation.

Use your insurance company's provider directory on their website or app, call customer service, or ask providers directly if they accept your insurance. Provider networks can change, so verify before each appointment, especially with new providers.

Emergency rooms are for life-threatening conditions and are typically covered even out-of-network. Urgent care is for non-emergency but immediate needs (like minor injuries or infections) and usually costs less than ER visits. Many plans have different copays for each type of care.