Health Insurance Guide

Health insurance helps pay for doctor visits, hospital stays, prescriptions and preventive care, and protects you from very large medical bills. In the United States, most people get coverage through an employer, a government program or the ACA Marketplace.

Where Americans get health insurance

• Employer-sponsored plans: the most common source of coverage. Employers usually pay part of the premium.
• ACA Marketplace: individual and family plans available through HealthCare.gov or your state’s exchange, with financial help based on income.
• Medicare: for people 65 and older and some people with disabilities.
• Medicaid and CHIP: free or low-cost coverage for eligible low-income adults, children, pregnant people and others.

Key terms to understand

• Premium: what you pay every month for the plan.
• Deductible: what you pay for covered care before the plan starts paying.
• Copay and coinsurance: your share of the cost of a service after the deductible.
• Out-of-pocket maximum: the most you pay for covered services in a year; after that, the plan pays 100 percent of covered costs.
• Network: the doctors and hospitals that have contracts with your plan.

HMO, PPO, EPO and POS plans

HMOs usually require you to use in-network providers and get referrals to see specialists, but tend to have lower premiums. PPOs offer more flexibility to see out-of-network providers for a higher cost. EPOs cover only in-network care but often do not require referrals, and POS plans combine features of HMOs and PPOs.

When you can enroll

Marketplace plans can be purchased during the annual Open Enrollment Period, which runs from November 1 to January 15 in most states. Outside that window, you generally need a qualifying life event, such as losing other coverage, getting married, having a baby or moving, to use a Special Enrollment Period. Medicaid and CHIP accept applications year-round.

Read more: the ACA Marketplace explained.

This guide is for general information only and is not insurance, legal, tax or financial advice. Coverage, rules and prices vary by state, insurer and policy. Always read your policy documents and speak with a licensed insurance agent or your state insurance department before making a decision.