Health insurance in the US: a beginner's guide
In short: US health care is expensive without insurance. Most people get coverage through an employer, the Health Insurance Marketplace (HealthCare.gov or a state site), Medicaid or CHIP, or, for many students, a school plan. Compare plans on the premium and what you would pay when you use care: deductible, copays, coinsurance and the out-of-pocket maximum.
The words on every plan
- Premium: what you pay each month for the plan.
- Deductible: what you pay for covered care each year before the plan starts paying its share.
- Copay: a fixed amount for a service, such as $30 for a doctor's visit.
- Coinsurance: your percentage of the cost after the deductible, such as 20%.
- Out-of-pocket maximum: the most you pay for covered, in-network care in a year. After that, the plan pays 100%.
- Network: the doctors and hospitals the plan has agreements with. Going outside it can cost much more.
Plan types
- HMO: you usually need to use in-network providers and get a referral to see a specialist.
- PPO: more freedom to see out-of-network providers, at a higher cost.
- EPO and POS plans sit somewhere between the two.
A lower premium often means a higher deductible. If you expect to see doctors often or take regular medicines, a plan with a higher premium but lower costs when you use care may cost less over the year.
Where to get coverage
- Through work: many employers offer plans and pay part of the premium. You usually sign up when you start or during the yearly enrollment window.
- The Marketplace: HealthCare.gov or your state's own site. Depending on your income, you may get help paying the premium (what is APTC?). Find your state's official site with our marketplace finder. Open enrollment for the federal Marketplace usually starts on 1 November; check the deadlines for your state.
- Medicaid and CHIP: free or low-cost coverage for people with lower incomes and for children, run by each state.
- Students: many colleges require students, especially international students, to have health insurance, often through a school plan. Ask your school's international office.
Who can use the Marketplace or Medicaid depends on things like where you live, your income and your immigration status. HealthCare.gov has a page explaining coverage for immigrants; this site does not give immigration advice.
Outside open enrollment
Life changes such as losing other coverage, moving, getting married or having a baby can open a special enrollment period, usually 60 days, when you can sign up or change plans.
Protections worth knowing
- Marketplace plans must cover many preventive services, such as certain screenings and vaccines, at no cost when you use an in-network provider.
- The No Surprises Act protects you from most surprise bills for emergency care and for some out-of-network care at in-network hospitals.
- Check every bill against the explanation of benefits (EOB) your insurer sends, and ask about anything you don't understand.
For health topics themselves, our sister site GetReady Health has plain-language guides.
Handy tools
- Monthly budget planner: see what is left each month and how your spending splits up.
- Salary converter: hourly, weekly, monthly and yearly pay, side by side.
General information, not financial or insurance advice. Coverage, prices and rules vary by state, insurer and policy. Read your policy and check with the insurer, a licensed agent or your state insurance department before you decide.
Sources
- HealthCare.gov: Glossary of health coverage terms
- HealthCare.gov: Health plan types (HMO, PPO, EPO, POS)
- HealthCare.gov: Special enrollment period
- HealthCare.gov: Coverage for immigrants
- HealthCare.gov: Preventive care benefits for adults
- CMS: No Surprises: understand your rights against surprise medical bills
- Medicaid.gov: Medicaid and CHIP