🏥 Basics of Health Insurance in the U.S.
- Health insurance helps cover medical costs like doctor visits, hospital care, prescriptions, preventive services, and sometimes dental/vision.
- Without it, healthcare can be extremely expensive — even routine visits or emergencies can cost thousands.
- Coverage is provided through private insurers, employers, or government programs.
🔑 Main Types of Health Insurance
1. Employer-Sponsored Insurance
- Most Americans get insurance through their employer.
- Employers usually cover part of the monthly premium, making it cheaper than buying independently.
- Plans differ in coverage, networks, and out-of-pocket costs.
2. Marketplace / ACA Plans
- Created under the Affordable Care Act (ACA).
- Accessible via HealthCare.gov or state exchanges.
- Offers subsidies (tax credits) if your income qualifies, lowering premiums.
- Covers “essential benefits” like preventive care, maternity, mental health, and prescriptions.
3. Government Programs
- Medicare: For people 65+ and some younger with disabilities.
- Medicaid: For low-income individuals/families (eligibility varies by state).
- CHIP: Children’s Health Insurance Program for kids in low-income households.
- Veterans Health Administration (VA): For military veterans.
4. Private Insurance (Direct Purchase)
- Bought directly from insurers (outside ACA marketplace).
- May offer broader networks or specialized plans, but no subsidies.
5. Short-Term / Catastrophic Plans
- Temporary coverage for gaps (e.g., between jobs).
- Usually cheaper, but limited coverage and often exclude pre-existing conditions.
💳 Key Costs to Understand
- Premium: Monthly payment to keep coverage active.
- Deductible: Amount you pay before insurance starts covering costs.
- Copay: Fixed fee for a service (e.g., $20 doctor visit).
- Coinsurance: Percentage you pay after deductible (e.g., 20%).
- Out-of-Pocket Maximum: Cap on yearly expenses — once reached, insurance pays 100%.
🌐 Common Plan Types
- HMO (Health Maintenance Organization): Lower cost, must use in-network providers, needs referrals for specialists.
- PPO (Preferred Provider Organization): More flexible, can see out-of-network providers, no referrals needed.
- EPO (Exclusive Provider Organization): In-between HMO and PPO; coverage limited to in-network, but no referrals.
- POS (Point of Service): Requires referrals, but allows some out-of-network coverage.
✅ Tips for Choosing a Plan
- Check your needs: Do you visit doctors often, need specialists, or have ongoing prescriptions?
- Budget wisely: Low premium = higher deductible, good for healthy individuals. High premium = lower out-of-pocket, better if you need frequent care.
- Check provider networks: Ensure your preferred doctors/hospitals are included.
- Review benefits: Look at mental health, maternity, dental/vision, and prescription coverage.
🚨 Enrollment Periods
Employer plans: Typically have their own annual enrollment window.
Open Enrollment (ACA): Usually Nov–Jan each year.
Special Enrollment: You qualify if you have a life change (marriage, job loss, moving states, new baby, etc.).