GoodRx Guide
Health Insurance: Your GoodRx Guide
Overview
Health insurance helps pay for your medical, surgical, and prescription drug expenses. It offers protection from high costs through negotiated rates with healthcare providers. You typically pay monthly premiums and a share of the costs when you receive care.
Most people in the U.S. have some form of health insurance. About half, or 158 million people, get insurance through jobs. But health plans are unequal — both in costs and coverage. People with plans that leave them exposed to high costs and financial risk are considered “underinsured.” Of the nearly 90% of Americans who have coverage, 29% are underinsured.
There are more ways to enroll in a health plan now than there were 10 years ago. And worries about insurers rejecting people because of preexisting medical conditions are mostly a thing of the past. You may buy or get coverage from:
Your employer
A government-run health insurance marketplace
A private health insurance company
Public programs
The government offers several public health insurance programs. Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) are among the best known. Each has different requirements, restrictions, and coverage.
Medicare is a federal health insurance program for adults age 65 and over, younger people with disabilities, and those with permanent kidney failure or ALS (Lou Gehrig’s disease). It has different parts and options, such as coverage for prescription drugs.
Medicaid provides free or low-cost health insurance to low-income families and children, pregnant women, older adults, and people with disabilities. All but 12 states have expanded eligibility to adults earning up to 138% of the federal poverty limit under the Affordable Care Act (ACA).
CHIP offers low-cost health coverage for children in families who earn too much income to qualify for Medicaid. CHIP also covers pregnant women in certain states. All states provide a version of CHIP, but the program’s name can vary.
Private insurance
Private — also known as commercial — health insurance is available through employers as well as directly from insurers. Under the ACA, any company with more than 50 workers must offer a basic health plan and cover at least 60% of the cost, or it may pay a penalty.
Some of the largest U.S. private, for-profit health insurance companies are:
Some of the less common forms of private insurance include:
Short-term health plans provide inexpensive, temporary coverage. These plans fall outside ACA rules. They generally don’t cover preexisting conditions and offer such limited benefits that you may pay a lot of money out-of-pocket if you need care.
Catastrophic health plans operate under ACA rules. But you have to be under age 30 or have a hardship to qualify.
Plan types
Once you get coverage, next comes understanding the different types of plans an insurer may offer. Monthly premiums, cost-sharing structures, and covered care can vary greatly between types. The most common are:
PPO: Preferred provider organization plans have a network of participating providers. You pay less for care from “in-network” providers and more if you visit facilities and providers outside the network.
HMO: Health maintenance organization plans provide care from a network of specific providers and hospitals. These plans often don’t cover any care from providers outside their network, except in emergencies.
EPO: Exclusive provider organization plans are a hybrid option. They don’t require a primary care provider referral to see a specialist. But out-of-network care isn’t provided and visits require pre-approval.
POS: Point-of-service plans combine qualities of HMO and PPO plans. You pay less if you use in-network providers but may need a referral if you want to see a specialist.
Costs
Health insurance costs vary based on your plan and where you get coverage.
With a job-based plan, your employer may cover some or all of your monthly premium costs. But high-deductible health plans have become more common. You may be able to offset out-of-pocket costs with tax-favored money you set aside in a health savings account (HSA) or flexible spending account (FSA).
If you enroll through the insurance marketplace via Healthcare.gov, your monthly costs will depend on:
The plan tier you choose (Bronze, Silver, Gold, or Platinum)
Government subsidies you’re eligible for
Your income
If you enroll in Medicare, costs will depend on the parts you choose (A, B, C, or D), your income, and the specific plan or plans you pick.
Aside from monthly premiums, you may be responsible for:
A deductible: The amount you pay for services before your health plan begins paying its share
Copayment, or “copay”: A fixed rate that you pay for services like office visits
Coinsurance: A percentage of the charges
Coverage
The ACA requires marketplace health plans to offer 10 essential health benefits such as prescription drugs and maternity care. It also includes a host of preventive care services for no cost to enrollees such as health screenings and vaccinations. Other examples include:
Medicare covers routine vaccinations and annual wellness visits. Because of COVID-19, Medicare made it easier for enrollees to access telehealth services for those who prefer video visits. Medicare Advantage plan enrollees may have more telehealth coverage than those in original Medicare.
If you’re a veteran, you may receive VA Health Benefits. Veterans can receive low-cost care at any of the 1,200 VA medical facilities in the U.S. VA benefits may coordinate with other coverage such as Medicare or private insurance. Active-duty military members and their families receive coverage through Tricare.
Troubleshooting
The ACA expanded coverage to millions of Americans starting in 2014. But about 30 million remain uninsured, and as many as 40 million are underinsured. The American Rescue Plan made coverage temporarily cheaper for marketplace plans and job-based COBRA plans.
Some research suggests having continuous coverage improves health outcomes. But insurance alone doesn’t guarantee a smooth ride. Your insurer may decide the surgery you’ve been waiting for isn’t “medically necessary.” Or a medication you need may drop off your insurer’s formulary (list of covered drugs). A healthcare bill may cause financial panic.
Before you give up and either pay a bill out of frustration or ignore it and end up in debt, remember to:
Use your insurer’s appeals process.
Contact your state department of insurance or attorney general’s office if you’re not getting results.
Take heart. New protections from surprise medical bills should help. Call the No Surprises Help Desk at 1-800-985-3059 with questions or complaints.
Common concerns
Check to see if you’re eligible for free or low-cost health insurance through Medicaid or Healthcare.gov. If you don’t have health insurance, you may find free or low-cost healthcare services at community health centers and mobile health clinics. The National Association of Free & Charitable Clinics has a clinic-locator tool. Planned Parenthood provides sexual and reproductive healthcare on a sliding-scale fee basis.
Enrollment periods vary depending on the kind of coverage you’re signing up for. If you have employer-based health insurance, you can compare and switch plans once a year. Open enrollment often lasts a few weeks in the fall. Open enrollment for Medicare runs October 15 through December 7. For many coverage types, special enrollment periods let you sign up after a life change — such as a new job, a move, or a child’s birth — outside open enrollment periods.
You may have heard of nontraditional ways to pay for medical expenses, like pooling money with others in a healthcare sharing plan or raising funds through crowdsourcing. But beware: In some cases, these alternatives can affect your coverage options. A windfall from a platform like GoFundMe could hurt your eligibility for Medicaid or CHIP that requires income reporting. Unlike health insurance, which is regulated, sharing ministries offer no legal protection to ensure claims payment.
Because of the ACA, many health plans must cover preventive care benefits, including diet coaching if you’re at risk for conditions like diabetes. But there can be a wide variety of options beyond coverage for health screenings, certain kinds of counseling, and vaccines. Some job-based health plans may provide incentives such as cash or lower premiums for participating in wellness programs. Some may ask workers to complete health risk assessments. Contact your health plan to learn more.
When you first sign up for Medicare, you can choose original Medicare (Parts A and B) or Medicare Advantage, which bundles the parts together. Those who pick original Medicare may add Medicare supplemental insurance, called Medigap, to cover out-of-pocket costs such as deductibles and copays. Enrollees who choose Medicare Advantage may get benefits beyond original Medicare, but they can’t also get Medigap. Some may need Part D coverage for prescription medications.
References
Centers for Disease Control and Prevention. (2021). Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2019.
Centers for Medicare & Medicaid Services. (2021.) Medicare.gov.
Centers for Medicare & Medicaid Services. (2021.) Medicaid.gov.
Centers for Medicare & Medicaid Services. (2022). Complaints about medical billing.
Commonwealth Fund. (2019). Underinsured rate rose from 2014-2018, with greatest growth among people in employer health plans.
Commonwealth Fund. (2021). Will the American Rescue Plan reduce the number of uninsured Americans?
Defense Health Agency. (2021). Tricare.mil.
Department of Health & Human Services. (2021). Healthcare.gov.
Department of Health & Human Services. (2021). The 'metal' categories: bronze, silver, gold & platinum.
Department of Health & Human Services. (2021). Preventive health services.
Department of Health & Human Services. (2021). Preventive care benefits for adults.
Department of Health & Human Services. (2021). Preventive care benefits for children.
Department of Health & Human Services. (2021). Preventive care benefits for women.
Department of Health & Human Services. (2021). Your total costs for health care: Premium, deductible & out-of-pocket costs.
Department of Health & Human Services. (2021). What Marketplace health insurance plans cover.
Health Resources & Services Administration. (2018). What is a health center?
Kaiser Family Foundation. (2019). Employer responsibility under the affordable care act.
Kaiser Family Foundation. (2019). Health insurance coverage of the total population.
Kaiser Family Foundation. (2020). 2020 Employer health benefits survey.
Medicare.gov. (2021). Medicare costs at a glance.
Medicare.gov. (2021). Telehealth.
Medicare.gov. (2021). Yearly "wellness" visits.
Rogers, M., et. al. (2018) Interruptions in private health insurance and outcomes in adults with type 1 diabetes: A longitudinal study. Health Affairs.
Statistia. (2021). Largest health insurance companies in U.S. in 2021, by membership.
U.S. Department of Veterans Affairs. (2021). VA.gov.
