Health insurance provides financial protection against medical costs incurred due to illness or injury. It spreads the risk of high healthcare costs among a large pool of members, allowing costs to be paid through regular premiums. Health insurance helps ensure access to healthcare services without incurring unaffordable out-of-pocket expenses. It gives peace of mind knowing that you and your family are protected in case of unexpected health issues.
There are several types of health insurance plans with varying levels of coverage, costs, and provider networks. Choosing the right plan requires understanding key terms, coverage details, exclusions, limitations, and cost-sharing provisions. This article provides an overview of the meaning of health insurance and the major types of plans available.
What is Health Insurance?
Health insurance is a contract between an insurance provider (insurance company or government agency) and an individual or employer. It requires the payment of premiums or taxes in exchange for the insurance provider covering all or a portion of medical expenses incurred.
The purpose of health insurance is to provide financial security by protecting against unexpected high medical costs. It allows sharing of healthcare risks among a large pool of members. Those who remain healthy subsidize the costs of those who get sick.
Health insurance gives access to medical services and providers at lower negotiated rates. The insurance provider directly pays the healthcare providers, so the individual does not have to pay the full costs out-of-pocket.
Key Elements of Health Insurance
There are several key elements that make up a health insurance plan:
Premiums:The upfront amount paid every month for coverage. Premiums are based on the level of coverage, whether for an individual or family, age, location, tobacco use, and other factors.
Deductible:The amount paid out-of-pocket before insurance starts to pay. Plans may have both individual and family deductibles. High deductible idea have lower premiums but higher out-of-area costs.
Copayments: Flat dollar amounts paid when receiving certain services, usually when visiting doctors or getting prescriptions. Copays do not go towards the deductible.
Coinsurance: Percentage of costs shared with the insurance company after meeting the deductible. For example, the plan pays 80% while the member pays 20%.
Out-of-pocket maximum:The most paid out-of-pocket in a year, including the deductible, copays, and coinsurance. After this limit is reached, the plan covers 100% of costs.
Covered services: List of medical services, tests, procedures, and medications at least partially covered. Important to review details of coverage for any exclusions.
Provider network: Doctors, hospitals, pharmacies, and other providers contracted with the insurance company to provide care at negotiated lower costs. Using out-of-network providers results in higher out-of-pocket costs.
Major Health Insurance Types
There are several broad categories of health insurance plans available today:
Employer-Sponsored Group Health Plans
Most Americans have employer-provided group health insurance. Employees are offered a choice of health plans and coverage extends to dependents. Employers usually pay a large portion of the premiums as an employee benefit. These group plans must meet minimum standards required by law.
Individual and Family Plans
People without employer coverage can purchase individual and family plans directly from insurance companies or government exchanges. Options include Affordable Care Act (ACA) qualified plans with income-based subsidies for qualifying individuals.
Federal health insurance program primarily for adults aged 65+ and people with certain disabilities. Medicare has different parts that cover hospital care (Part A), medical services (Part B), and prescription drugs (Part D).
Joint federal and state program that provides free or low-cost health coverage for low-income families and individuals. Eligibility is based on income, household size, disability, and other factors. Benefits vary by state.
Children’s Health Insurance Program (CHIP) provides coverage for children in families with incomes too high to qualify for Medicaid but too low to afford private insurance. Implemented jointly by states and federal government.
Allows employees who lose or leave their jobs to pay to continue group health benefits temporarily. Usually available for 18-36 months by paying the full premium including portion previously paid by the employer.
Veterans Health Care
Healthcare program from the Department of Veterans Affairs providing coverage for qualifying military veterans at VA facilities. Requires enrollment and eligibility verification.
Health insurance program for military personnel, retirees, and their families. Administered by the Department of Defense with different plans available depending on status.
Private Health Insurance Plans
Private health insurance includes group plans through an employer or union as well as individual and family plans purchased directly. There is a great deal of variation among private health plans but most fall into one of these categories:
Health Maintenance Organizations (HMOs)
- Members must get care from in-network providers to get coverage except in emergencies.
- Requires choosing a primary care physician to manage care and referrals to specialists.
- Low out-of-pocket costs for in-network care, but high costs for out-of-network care.
- Preventive care is usually free and office visit copays are low, around $20-40.
Preferred Provider Organizations (PPOs)
- Members pay less when using in-network providers but can go out-of-network and still get coverage.
- Does not require a primary care physician or referrals to see specialists.
- Deductibles and coinsurance are usually higher than HMOs, around 10-20% of costs.
- Provides more flexibility to choose providers than HMOs.
Point of Service (POS) Plans
- Combines features of HMOs and PPOs. Members choose an in-network primary care doctor to coordinate care.
- Lower costs when staying in-network but still get some coverage out-of-network.
- Requires referrals to see specialists to get the best coverage rates.
High-Deductible Health Plans (HDHPs)
- Much lower premiums but very high deductibles, often $1000 to $7000 per person.
- Best if healthy and have money set aside for medical expenses.
- Often paired with tax-exempt Health Savings Accounts (HSAs) to pay deductibles.
Catastrophic Health Insurance
- Bare-bones coverage meant as a safety net for worst-case scenarios.
- Very high deductibles up to $8000 per person. Only covers essential services prior to deductible.
- Low monthly premiums so can be paired with HSAs. Mainly used by younger healthy people.
Short-Term Limited-Duration Insurance
- Temporary basic coverage, often 3-12 months. Does not meet ACA standards.
- Low monthly costs but limited benefits, big exclusions, and caps on spending.
- Sold as a stopgap between comprehensive insurance plans.
Government-Sponsored Health Plans
Government-sponsored health insurance provides coverage for certain groups including seniors, low-income families, children, veterans, and military personnel. These plans have complex eligibility rules but provide essential access to healthcare services.
The federal Medicare program primarily serves Americans over 65 years old and younger people with long-term disabilities. There are some parts to Medicare coverage:
Medicare Part A: Hospital insurance covering inpatient care in hospitals, skilled nursing facilities, hospice, and home health care. Most people get premium-free Part A.
Medicare Part B: Medical insurance that covers doctor’s services, outpatient procedures, preventive screenings, lab tests, medical equipment, and ambulance transportation. Requires monthly premiums.
Medicare Advantage (Part C): Private insurance plans that provide Medicare benefits. Offers all Part A and Part B coverage plus sometimes extras like vision or dental.
Medicare Prescription Drug Coverage (Part D): Add-on plans for prescription drug coverage offered through private insurers approved by Medicare. Monthly premiums vary by plan.
In addition to Original Medicare parts A and B, most enrollees purchase supplemental coverage through private Medigap plans, Medicare Advantage, or retiree medical plans to lower out-of-pocket costs. Low-income seniors may qualify for Medicaid to assist with Medicare premiums and cost-sharing.
Medicaid provides free or low-cost health coverage for low-income adults, children, pregnant women, elderly adults, and people with disabilities. Eligibility and benefits vary greatly by state as Medicaid is jointly administered by states and the federal government.
Over 70 million Americans are covered by Medicaid, representing one-fifth of the population. Enrollees must meet income and asset limits which are higher for children and pregnant women. Medicaid covers a comprehensive set of services including hospital care, doctor visits, long-term care, and prescription drugs.
Medicaid expansion under the Affordable Care Act allowed states to broaden eligibility to more low-income adults starting in 2014. This expanded Medicaid to cover more non-elderly, non-disabled adults without dependents. However, 12 states have opted not to expand Medicaid eligibility.
The Children’s Health Insurance Program, or CHIP, provides coverage to children in families with incomes too high to get Medicaid but too low to afford private health plans. Income limits range from 140% to over 400% of the federal poverty level depending on the state.
CHIP health plans provide comprehensive benefits including routine check-ups, immunizations, doctor visits, prescriptions, dental and vision care, hospital care, mental healthcare, and more. Cost-sharing is typically very low or nonexistent.
The program is funded jointly by states and the linked government. Families pay low monthly premiums and enrollment fees vary by state. CHIP enrollment reached over 10 million children and pregnant women in 2021.
TRICARE provides health coverage for active duty and retired military service members and their families. It is administered by the Department of Defense and was launched in 1995, replacing the former CHAMPUS program.
There are several TRICARE plans available depending on the beneficiary’s military status:
TRICARE Prime – HMO-style plan for active duty members who get care from military facilities and designated providers. Minimum out-of-pocket costs.
TRICARE Select – A PPO-like plan allowing wider provider choice. Retirees and family members typically choose this option. More out-of-pocket costs than Prime.
TRICARE for Life – Secondary coverage for Medicare-eligible military retirees 65 and older. Wraps around Medicare benefits.
TRICARE Reserve Select – Part-time reservists who qualify can purchase this coverage when not on active duty. Member-only or family plans.
Veterans Health Care
The Veterans Health Administration manages the nation’s largest integrated health care system, providing coverage to nearly 9 million enrolled veterans each year. VA health benefits are funded through federal tax dollars and require no premiums or cost-sharing from veterans.
Eligible veterans include those who served in active military, naval, or air service and were discharged under conditions other than dishonorable. Minimum duty requirements apply such as 24 months of continuous active duty service. Reservists and National Guard members who were called to active duty by federal order also qualify for VA coverage.
The VA health system is not an insurance plan but rather a direct provider of care through an integrated network of over 1,200 VA facilities, clinics, and programs. Services covered include hospital care, preventive care, mental health services, women’s health, prescription drugs, and long-term care. Veterans with lower incomes and service-related disabilities have access to the most generous benefits.
- Health insurance helps pay for medical expenses and protects against financial hardship due to illness or injury. It spreads the risk across a group of enrollees.
- Main components of health insurance include premiums, deductibles, copays, coinsurance, out-of-pocket maximums, covered services, and provider networks.
- Major insurance categories include employer plans, individual plans, Medicare, Medicaid, CHIP, COBRA, veterans benefits, and military coverage like TRICARE.
- Types of private insurance include HMOs, PPOs, POS plans, HDHPs, catastrophic plans, and short-term insurance.
- Government-run coverage includes Medicare for seniors, Medicaid and CHIP for low-income groups, TRICARE for military, and Veterans Affairs health programs.
Understanding the basics of health insurance terminology and plan types allows informed decision-making when selecting appropriate coverage for your needs. Consult with a health insurance broker or state/federal marketplace navigators if you need assistance. Make sure to compare all costs and covered benefits before enrolling.
This comprehensive overview covers the meaning of health insurance and provides details on the major types of insurance plans available in the current healthcare system. Both private insurance options and government-sponsored coverage through Medicare, Medicaid, CHIP, VA health benefits, and TRICARE are explained. Key takeaways include understanding premiums, deductibles, copays, coinsurance, provider networks, covered services, exclusions, and limitations in health insurance policies.