There are a few things you or your family need to know when choosing health insurance, such as:

  • Where you can get coverage
  • What plans are available to you
  • How to decide on a plan that might work for you

Where can I get coverage?

Your answers to some basic questions will tell you where to look for health insurance:

  • How old am I?
  • What state do I live in?
  • Can I get insurance through my job?
  • Am I eligible for coverage on my spouse's or parent/legal guardian's plan?
  • Am I a US citizen, US national, or legal US resident?
  • How much money do I make per year?
  • Have I served in the US Armed Services?
  • Am I a parent or expecting a child?
  • Do I have end-stage renal disease, Lou Gehrig's disease (ALS), a disability, or am I legally blind?

Depending on your answers, you might be able to get insurance from several places. You may have lots of options available to you or your family, but to get an idea of the first place to look, click on what best describes you:

Your job may offer Employer-Sponsored Insurance (ESI); however, some companies do not offer insurance

See what types of plans might be available

Employer-Sponsored Insurance (ESI) may be available through your spouse's employer

See what types of plans might be available

Your employer may offer health insurance, but if not, take a look at the Health Insurance Marketplace

See what types of plans are available

Talk to your parent or legal guardian to see if you are covered. If you are not, you may have to look for health insurance on your own, or through the Health Insurance Marketplace.

You and your family might want to look for health insurance on your own, or through the Health Insurance Marketplace. Talk to your parent or legal guardian about signing up for a plan that will cover your whole family, and together you can see what types of plans might be available.

Take a look at the Health Insurance Marketplace

See what types of plans might be available

Take a look at the Health Insurance Marketplace

See what types of plans might be available

You may be able to get coverage through Medicaid or other sources. Here are 2 places you can look:

Medicaid
See if you are one of the adults who qualify at Healthcare.gov or visit Medicaid.gov for more information
or
Health Insurance Marketplace
See what types of plans might be available

Medicare might be a good choice for you

See if you qualify

There are 2 places you should start looking:

Medicare
See if you qualify by visiting SocialSecurity.gov
or
Medicaid
See if you qualify by visiting Healthcare.gov

There are 2 places you should start looking:

Medicaid can cover children and families with low income
See if you qualify
or
The Children's Health Insurance Program (CHIP) covers children and, in some states, pregnant mothers
See what types of plans might be available

The Health Insurance Marketplace offers some special benefits
View insurance options at www.healthcare.gov

Some services are available from the Indian Health Service
Visit IHS.gov to learn more

There are 2 places you should start looking:

Veterans Health Administration (VA) if you are an active member of the military
Apply at VA.gov
or
TRICARE if you are retired from the military
Learn more at TRICARE.mil

Download the full Health Insurance and You PDF for more details on each of the sources of health insurance listed above.

Why do I need health insurance?

Why do I need health insurance?

There are some very good reasons

What types of plans are available?

  • If you can get coverage from your employer, a private insurer, or the Health Insurance Marketplace, you will likely have more than one plan to choose from
  • Did you know that most plans are required to provide 10 essential health benefits:
    1. Preventive services (such as immunizations and mammograms) and management of chronic diseases such as diabetes
    2. Emergency services
    3. Hospitalization
    4. Laboratory tests
    5. Maternity and newborn care
    6. Mental health and substance-abuse treatment
    7. Outpatient care (doctors and other services you receive outside of a hospital)
    8. Pediatric services, including dental and vision care
    9. Prescription drugs
    10. Rehabilitation services

Your access to doctors, hospitals, and other health care providers, and how much you'll pay out of your own pocket for each service vary from plan to plan. That's why it's good to look at the types of plans commonly offered to see what the differences are.

Some preventive services may be available free of charge to qualifying patients in many plans.

Preventive services (such as immunizations and mammograms) and screening tests are covered at no cost under most plans to qualifying patients.

View the full list of preventive services

What are some of the types of plans offered by employers and private insurers?

Private insurers and Employer-Sponsored Insurance (ESI) often have similar types of plans to choose from. While the actual plan names may be different, these are the most common types of plans offered. The type of plan may be included in the name, or it may be called something else, so be sure to ask your company's benefits manager or insurance company to help you understand your options.

All plans will have some things in common. For example, each plan has a monthly payment (called a premium) that you will pay even if you do not use health insurance that month. Most plans will cover basic care and prescription medicines, but you should review the list of covered drugs for your plan options to see what medicines are covered and how much they might cost. Learn more about prescription medicine coverage.

  • Health Maintenance Organizations (HMOs) are plans that require you to use providers (doctors and services) that they have selected (called a network)
  • Out-of-network coverage
    While these plans usually cover most or all of the cost of seeing doctors (or using other services) within their network, you likely will have to pay all of the cost out of your own pocket to use doctors and services that are not part of their network
  • Claim paperwork
    These plans handle most of the claim paperwork
  • Specialists/referrals
    To see a specialist, you will need a referral (like getting permission) from your primary care physician (PCP)
  • Preauthorization
    HMOs generally do not make you get approval (preauthorization) from your insurance company before certain tests (like lab tests or x-rays) or treatments, but you may need a referral for some tests or treatments

Costs

In-network care: $$$
Out-of-network care: $$$

Don't forget about other costs (like premiums and deductibles).

Good for

People who want to spend less on insurance and are open to using a primary care physician (PCP) from their plan's list and working with that doctor to set up tests and appointments with specialists

Not good for

People who like to have a choice of which doctors to see and where to get health care

  • Exclusive Provider Organizations (EPOs) are similar to HMO plans and require you to use providers (doctors and services) that they have selected (called a network)
  • Out-of-network coverage
    While these plans usually cover most or all of the cost of seeing doctors (or using other services) within their network, you likely will have to pay all of the cost to use doctors and services that are not part of their network
  • Claim paperwork
    These plans handle most of the claim paperwork
  • Specialists/referrals
    You will likely not need a referral from your primary care physician (PCP) to see a specialist or for certain tests
  • Preauthorization
    You will need approval (preauthorization) from your insurance company before certain tests (like lab tests or x-rays) or treatments

Costs

In-network care: $$$
Out-of-network care: $$$

Don't forget about other costs (like premiums and deductibles).

Good for

People who want to spend less on insurance and are open to using a primary care physician (PCP) from their plan's list and working with that doctor to set up tests and appointments with specialists

Not good for

People who like to have a choice of which doctors to see and where to get health care

  • Preferred Provider Organizations (PPOs) let you choose to get care from doctors and services within or outside of the plan's group of selected doctors (network)
  • Out-of-network coverage
    These plans will cover some of the cost if you decide to use doctors and services that are out-of-network, but you will pay more than if you had stayed in network
  • Claim paperwork
    You must file claim paperwork yourself if you use doctors or services that are not on your plan's list
  • Specialists/referrals
    Most PPOs do not need referrals from your primary care physician (PCP) before you see a specialist
  • Preauthorization
    PPOs may require you to get approval (preauthorization) from your insurance company before you get certain tests or treatments. Check your plan to be sure

Costs

In-network care: $$$
Out-of-network care: $$$

Don't forget about other costs (like premiums and deductibles).

Good for

People who like the option of choosing doctors outside of their plan's network and can afford to spend more on premiums and other out-of-pocket expenses compared to other plans

Not good for

People who are concerned about paying extra money and costs or who do not want to get approval from their insurance company before getting some tests or treatments

  • Like PPOs, Point-of-Service plans (POS) let you choose to get care from doctors and services within or outside of the plan's group of selected doctors (network)
  • Out-of-network coverage
    These plans will cover some of the cost if you decide to use doctors and services that are not on your plan's list, but you will pay more than if you had stayed in network
  • Claim paperwork
    You must file claim paperwork yourself if you use doctors or services that are not on your plan's list
  • Specialists/referrals
    POS plans may require referrals from your primary care physician (PCP) before seeing a specialist
  • Preauthorization
    Most POS plans do not require approval from your insurance (preauthorization) before getting certain tests or treatments unless it is for out-of-network care

Costs

In-network care: $$$
Out-of-network care: $$$

Don't forget about other costs (like premiums and deductibles).

Good for

People who like the option of choosing doctors outside of their plan's network, even at a higher cost, and can afford to spend more on coverage

Not good for

People who are concerned about paying extra money and costs or who do not want to get approval before seeing a specialist or getting some tests or treatment services out-of-network

  • A high deductible health plan (HDHP) can be a PPO, POS, or HMO with a low monthly cost (premium) but a high amount you must spend before insurance will start to share the cost with you (deductible)
  • HDHPs may include options for a Health Reimbursement Arrangement (HRA) or Health Savings Account (HSA), which you can learn more about below.
  • Out-of-network coverage
    HDHPs might count out-of-network services when trying to reach the deductible, or they might only count in-network services. They also might have differences in what is covered once you have reached the deductible, so be sure to check the plan details when choosing an HDHP
  • Claim paperwork
    This depends on what type of HDHP you have (HMO, PPO, etc)
  • Specialists/referrals
    This depends on what type of HDHP you have (HMO, PPO, etc)
  • Preauthorization
    This depends on what type of HDHP you have (HMO, PPO, etc)

Costs

In-network care: $$$
Out-of-network care: $$$

Don't forget about other costs (like premiums and deductibles).

Good for

People who are in good health and generally only see a doctor for routine care (sore throat, checkups, etc.), who don't take many prescription medicines, and who want to spend less each month on health insurance

Not good for

People who have a chronic condition and use health services often and who take a number of medicines on a routine basis

  • These plans also have high deductibles but they are the only type of plan that does not cover the 10 essential benefits listed above until after the deductible is met
  • Like a safety net, these plans cover only services in case of an accident or serious illness
  • They have a low monthly cost (premium) but a very high amount you must spend before insurance will start to pay (deductible)
  • You are eligible only if everyone covered by the plan is under 30 or if you qualify due to financial hardship
  • These plans do cover 3 primary care physician visits per year and most include a number of free preventive services, like immunizations and health screenings for qualifying patients

Costs

In-network care: $$$
Out-of-network care: $$$

Don't forget about other costs (like premiums and deductibles).

Good for

People who are under 30, in good health, confident that they won't have an issue, and want to spend less each month on health insurance

Not good for

People under 30 who have a chronic health condition and use health services often

I can help you with health insurance by sending you the right information at important times throughout the year.

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Health care spending accounts

Many plans also have accounts that you can set up to use to pay for care during the year. If you have a lot of out-of-pocket health costs, you might want to think about using a health care spending account.

The Out-of-Pocket Cost Tracker can help you use one of the health care spending accounts listed below. The Out-of-Pocket Cost Tracker is designed to be used on a computer with Adobe® Acrobat® Reader software, available here for free.

Health Saving Account (HSA)

  • Only available for use with an HDHP
  • Lets you add money from your paycheck before taxes; employers can contribute, as well
  • Used to cover the out-of-pocket costs of care, such as prescription medicines
  • Money in your HSA can be invested, the balance carried over from year to year if not spent, and it can be taken with you if you leave your plan or change employers

Health Reimbursement Arrangement (HRA)

  • Sometimes called a personal care account
  • You may only use for certain qualified expenses
  • Similar to an HSA but your employer puts money in instead of you
  • There may be a maximum on the value of an HRA
  • Interest is not earned on an HRA, and the amount does not transfer if you leave your job

Flexible spending account (FSA)

  • Funded by you or your employer
  • Unlike an HRA, you get to choose what qualified expenses are paid for
  • Money left at the end of the year may go back to your employer if not used

Follow along as different families pick a health insurance plan.

It's time to select a plan. Each of the people below are looking at their options for the year. They each have to think about their health care needs as they look at each plan. They also look at how much they will pay each month as a premium, whether their doctors are in their plan's network, whether their medicines are covered by their plan, and how much they might cost.

See examples of how each plan type might work out for the year for each of the families below. Note that these are just examples and do not represent what you might have to pay.

Michelle is young, healthy, and employed. She only uses health services like routine checkups at her physician covered by her health insurance. In the winter, she gets strep throat and visits her physician who prescribes a medicine to help her get better.

Plan Details

  • $100/month premium ($1,200/year)
  • $2,000 deductible
  • $4,000 out-of-pocket maximum

What Michelle Would Pay

  • $1,200 in premiums
  • $150 for doctor visit
  • $60 for medicine

$1,410 total out-of-pocket costs for Michelle

After looking carefully at each plan, Michelle chose a plan that had the lowest out-of-pocket cost, based on the amount of health care she expects to need in the coming year: an HDHP.

Brad and Christine are healthy and have 3 young, healthy children. Insurance through Christine's employer covers the many checkups the family uses to keep them healthy throughout the year. They have a doctor that they love and would like to continue seeing her. On their vacation in August, the family is in a minor car accident and needs to be transported to a hospital and cared for before being released the same day.

Plan Details

  • $450/month premium ($5,400/year)
  • $3,000 deductible
  • $4,000 out-of-pocket maximum

What Brad and Christine Would Pay

  • $5,400 in premiums
  • $4,000 for emergency services

$9,400 total out-of-pocket costs for Brad and Christine

After carefully looking at each plan, the total cost of care was not as important for Brad and Christine as being able to see their primary care physician. Even if they need a lot of care, the difference in cost is not a concern, so they chose to go with a PPO plan that allows them to see their preferred doctor, even though she is out of network.

Timothy and Heidi have health insurance directly through a private insurance company. Timothy has type 2 diabetes that requires regular appointments with his primary care physician and several specialists, lab tests, and prescription medicine.

Plan Details

  • $600/month premium ($7,200/year}
  • $5,000 deductible
  • $6,500 out-of-pocket maximum

What Timothy and Heidi Would Pay

  • $7,200 in premiums
  • $280 in Rx copays
  • $250 for testing supplies

$7,730 total out-of-pocket costs for Timothy and Heidi

Timothy and Heidi see the value in paying more each month for an HMO/EPO because it covers many of the regular services they use at little or no cost to them. After looking at each plan option, they decide that they would like to spread the cost of health care from month to month to avoid paying for each individual appointment, prescription, or test.

Why do I need health insurance?

What do all these terms and letters mean?

Use the glossary

What kinds of plans are available through the Health Insurance Marketplace?

If you are uninsured, your employer doesn't offer coverage, or you can't afford insurance, the Affordable Care Act created the Health Insurance Marketplace. It is made up of private health plans, and when you use the Health Insurance Marketplace you may be able to get lower costs on your monthly premiums and out-of-pocket costs.

If you are self-employed or just prefer to have other options outside of your employer, you may also want to look at these plans. Just know that if your job offers affordable health care, you might not be able to get financial assistance from the government.

There are 4 plans available in the Health Insurance Marketplace, and each one provides the 10 essential health benefits.

Which plan might be right for me?

First, consider what options are available to you based on your age, your heritage, your income, if you or a family member have a full-time job, etc. These things give you choices of plans that might meet your needs.

Second, consider your needs to predict how often you might use health care services. If you think you may need care more often, look for a plan with easy access to specialists or doctors you usually see.

To figure out what coverage you might need, ask yourself questions, such as:

  • Overall, how healthy have I been in the recent past?
  • Do my family members or I have any health conditions?
  • Am I beginning to experience any age-related health conditions?
  • Is my doctor in my network?
  • If I need to see a specialist or have a test, do I mind having to get a referral?
  • Am I active or do I have an active spouse or children playing sports? The risk of injury might be higher for people with active hobbies like rock climbing, recreational sports, or even running

Finally, consider the cost of your options. You can track your expenses this year and use the information to help you with insurance choices next year. The Out-of-Pocket Cost Tracker helps you record and add up your out-of-pocket costs so you can make informed decisions. The Out-of-Pocket Cost Tracker is designed to be used on a computer with Adobe® Acrobat® Reader software, available here for free.

  • Monthly premium (what your insurance will cost you every month, even if you don't use health care)
  • Out-of-pocket costs
    • Deductible—the amount you pay before insurance will begin paying for care
    • Copayment—a fixed dollar amount you pay after your deductible has been met (like $35 to see your doctor or $25 for your prescription medicine)
    • Coinsurance—this is similar to a copay, but it's a percentage of a medicine or service, rather than a fixed dollar amount (like 20% of the cost of your prescription medicine)
  • In-network versus out-of-network
    • Most health insurance companies have agreements with certain doctors or hospitals, creating a network of insurers and providers
    • If your doctor or local hospital is not in-network, it will cost more to receive care there than at one that is in your insurance company's network
    • Each plan has different networks and policies on how much you will have to pay for in-network and out-of-network care. Be sure to review the plan types above and think about if you will need to use out-of-network doctors, specialists, and hospitals
  • Get a better idea of what health insurance plans to look at based on how much they cost

If you are relatively young or healthy, you may want to look for a plan that has lower monthly costs (premiums) and a higher deductible since you will probably not need much care. If you are older or managing a health condition, you may want to look at a plan that spreads the cost out from month to month with a higher premium and limits the amount you pay each time you need care or prescription medicines.

Print or download a worksheet to fill in before choosing a plan.

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