Health insurance is a contract where you pay premiums to an insurance company in exchange for coverage of medical expenses. It helps protect you from high healthcare costs and provides access to medical services.

• Premium: Monthly payment to maintain coverage
• Deductible: Amount you pay out-of-pocket before insurance starts paying
• Copayment (Copay): Fixed amount for specific services (e.g., $30 doctor visit)
• Coinsurance: Percentage you pay for services after deductible (e.g., 20%)
• Out-of-Pocket Maximum: Yearly limit on your healthcare expenses (excluding premiums)

• HMO (Health Maintenance Organization): Requires PCP referrals for specialists; limited to network providers
• PPO (Preferred Provider Organization): More flexibility; can see specialists without referrals
• EPO (Exclusive Provider Organization): Network-only coverage (except emergencies)
• POS (Point of Service): Hybrid of HMO and PPO features
• HDHP (High-Deductible Health Plan): Higher deductible, lower premiums; often paired with HSA

Example Scenario:

• Plan: $2,000 deductible, 20% coinsurance, $30 PCP copay, $6,000 out-of-pocket max
• Incident: You break your arm
• Step 1: Pay $30 copay for emergency room visit
• Step 2: Pay 100% of costs until deductible of $2,000 is met
• Step 3: After deductible, pay 20% of costs until $6,000 total out-of-pocket reached
• Step 4: Insurance pays 100% for remaining costs that year

• In-network: Providers contracted with your insurance; lower costs
• Out-of-network: Higher costs, sometimes not covered at all
• Balance billing: When out-of-network providers bill you the difference between their charge and what insurance paid

• NOT a bill – shows how a claim was processed
• Details services, what insurance paid, and what you owe
• Review carefully for accuracy before paying bills

Under ACA, all marketplace plans must cover:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative services
8. Laboratory services
9. Preventive and wellness services
10. Paediatric services

• Open Enrolment: Yearly period (typically Nov 1–Dec 15) to enroll or change plans
• Special Enrolment Period: 60-day window after qualifying life events:
  • Marriage/divorce
  • Birth/adoption
  • Loss of other coverage
  • Move to new coverage area

1. Use preventive care (fully covered under ACA plans)
2. Choose generic drugs when available
3. Use telemedicine for non-emergency issues
4. Shop around for procedures (prices vary widely)
5. Ask about cash discounts if paying out-of-pocket
6. Use mail-order pharmacies for maintenance medications

Usually included:

• Hospital services
• Surgery
• Lab tests
• Imaging (X-rays, MRIs)
• Outpatient procedures

Usually NOT included:

• Premiums
• Copays for office visits (varies by plan)
• Services not covered by your plan

• Premiums
• Copays for office visits (varies by plan)
• Services not covered by your plan

1. Your health needs: Medications, expected procedures, regular care
2. Provider preferences: Are your doctors in-network?
3. Monthly vs. total costs: Lower premium ≠ cheaper overall
4. Prescription coverage: Formulary restrictions, tier pricing
5. Maximum out-of-pocket: Worst-case scenario protection

1. Verify coverage for specific services
2. Check network status of providers/facilities
3. Get pre-authorizations if required by plan
4. Ask about costs upfront when possible

1. Review EOB thoroughly
2. Contact provider to check for billing errors
3. File appeal with insurance company
4. Contact state insurance department if unresolved
5. Use independent review options if available

• Continue employer coverage after job loss
• You pay full premium + 2% administrative fee
• Available for 18–36 months depending on situation

• Medicaid: Based on income; state-run programs
• Medicare: Age 65+ or certain disabilities
  • Part A: Hospital insurance
  • Part B: Medical insurance
  • Part C: Medicare Advantage (private plans)
  • Part D: Prescription drug coverage

• Temporary coverage (3 months to 3 years)
• Lower premiums but limited coverage
• Often exclude pre-existing conditions
• Not ACA-compliant

• Not reviewing plan annually – needs change, plans change
• Seeing out-of-network providers without realizing
• Not using preventive care benefits
• Missing enrolment deadlines
• Assuming all services at in-network facility are in-network
• Not checking prescription coverage before switching plans
• Paying medical bills without verifying EOB first

• Telehealth expansion post-pandemic
• Price transparency rules (hospitals must post prices)
• No surprise billing protections (emergency/out-of-network)
• Insulin cost caps for many plans
• Mental health parity enforcement

• Insurance terms and regulations vary by state and plan
• Always review your Summary of Benefits and Coverage (SBC)
• Keep records of all communications with insurers and providers
• This information is current as of 2023; healthcare laws frequently change