Health insurance is a contract between you and an insurance company. You pay a monthly fee (called a premium), and in return, your insurer helps cover medical costs. This can include doctor visits, emergency care, surgeries, prescriptions, and more. By spreading risk across a large group of people, insurance makes healthcare more affordable and protects you from financial hardship in the event of unexpected medical issues.

How Do You Get Insurance?

There are multiple ways to get health insurance in the US:

1. Employer-Sponsored Plans

Most common source of insurance.
Your employer usually pays part of the premium.
Your portion is often paid pre-tax (lowering your taxable income).

2. Health Insurance Marketplace (HealthCare.gov)

Buy insurance directly if your job doesn’t offer it.
You may qualify for financial assistance based on income.

3. Private Insurance Companies

You can also shop for plans through insurance agents or directly from insurers.

4. Medicaid/CHIP

Free or low-cost insurance for low-income individuals and families.
Eligibility varies by state.

5. Medicare

For people 65 and older, or under 65 with certain disabilities.

Choosing a Plan and Enrolling

Choosing a Plan: High vs. Low Deductible

Type

Good for...

What you pay monthly

What you pay when you're sick

High Deductible

Low Deductible

People who rarely go to the doctor

Less each month

More when you need care

People who need regular care

More each month

Less when you need care

Some high-deductible plans let you open a Health Savings Account (HSA) to save money for medical costs.

Open Enrollment & Qualifying Life Events

When is Open Enrollment?

Marketplace plans (ACA): Nov 1 – Jan 15 (check your state for variations).
Medicare: Oct 15 – Dec 7.
Employer-sponsored plans: Varies by employer (usually in the fall).

What if I Miss It?

You can still enroll if you experience a Qualifying Life Event (QLE) like:

Getting married
Having a baby or adopting a child
Losing previous coverage
Moving to a new state

What If You Don’t Have Insurance?

Applying for Medicaid

Medicaid is free or low-cost health insurance from the government for people with low income.

How to apply:

Go to your state’s Medicaid website.
Fill out an application (you’ll need info about income, household size, etc.).
Wait to hear back if you’re approved.

Need help? You can ask a school counselor, social worker, or community health center for guidance.

How to Read Your Insurance Card

Here’s what those terms mean on your card:

Policy Number / Member ID / Subscriber ID
These mean the same thing. It’s your unique ID number used by your insurance company to track your plan and medical bills.
- Think of it like your student ID number, it’s just for you.
Group Number
If you get insurance through a parent’s job, you might see a group number. This tells the insurance company which company or group the plan is from.
Rx or Prescription Info
Some cards show a section for prescriptions (marked Rx). It might say how much your insurance pays for medicines.
- Not all cards have this!
- You might also see an RxBIN or RxPCN number, this just helps pharmacies send the claim to the right place.
Coverage Percentages
You may see two sets of numbers:
- In-Network: Lower cost, because your doctor works with your insurance company.
- Out-of-Network: Usually more expensive. You can still go, but you’ll pay more.
Insurance Company Contact Info
On the back or bottom of your card, you’ll see a phone number or website. You can use this to:
- Ask what’s covered
- Find in-network doctors
- Get help if you have a problem

What Is Secondary Insurance?

Sometimes people have two insurance plans. Here’s why:

You’re on your employer’s plan and also covered under a parent’s or spouse’s plan.
You have Medicare but need a supplement plan (Medigap).
You buy extra plans just for vision, dental, or things like cancer or accident insurance.

How It Works

Coordination of Benefits: Your main insurance (primary) pays first. Then your secondary insurance may help pay what's left.
Coverage Limits: Your secondary plan might not cover everything, so check for rules or waiting periods.
Premiums: You usually pay monthly for your secondary plan. Compare the cost to how much it could save you.

Secondary insurance can help you:

Pay less out of pocket
Cover services your main plan doesn’t
Be better protected if you have a chronic illness or big medical needs

Different Plan Types and Coverage Rules

Plan Type

How it works

PPO (Preferred Provider Organization)

OAP (Open Access Plus)

HMO (Health Maintenance Organization)

EPO (Exclusive Provider Organization)

POS (Point of Service)

HDHP (High Deductible Health Plan) + HSA

Most flexible. You can go to any doctor in the network, even in another state, and sometimes even outside the network (at a higher cost).

Like a PPO, you can see in-network providers nationwide, even out of state.

Least expensive. You must stay in-network (local area), and you usually need a referral to see a specialist. Out-of-network care is only covered in emergencies.

Similar to an HMO, but with a larger network. Only covers in-network care. May or may not require referrals.

Hybrid of HMO and PPO. You need referrals and pay less in-network. Out-of-network care costs more and is limited.

Low monthly premiums, high deductibles. Often paired with HSA, so you can deposit pre-tax money into your HSA to use for medical expenses.

Medicare vs. Medicaid

Feature

Medicare

Medicaid

Who it’s for

Who funds it

How to qualify

Out-of-pocket costs

Ages 65+ or younger people with disabilities

Federal government

Based on age/disability

Premiums, deductibles, copays

Low-income individuals and families

Federal + State governments

Based on income/family size

Often low or no cost, depending on income

Private vs. Public Insurance

Feature

Private Insurance

Public Insurance

Where it's from

Cost

Eligibility

Customization

Employer, marketplace, broker

Monthly premiums, deductibles, etc.

Anyone can apply

Many plan options

Government (state and/or federal)

Often lower costs, depending on eligibility

Based on income (Medicaid) or age/disability (Medicare)

Fewer plan types, but core benefits included

Estimating Medical Costs

Use these tools to estimate how much you’ll pay:

Insurance Provider Websites – Many have cost calculators.
Healthcare Bluebook – Find “fair prices” for services.
Hospital Transparency Tools – Hospitals must post prices online.
Good Faith Estimates – Ask your provider directly for a written estimate.
Marketplaces like Oscar, Sidecar Health, or Aetna – These may have tools built in.

How Do I File a Health Insurance Claim?

If your provider doesn’t file the claim for you, here’s what to do:

1. Complete a Claim Form

Find your insurance company's claim form on their website. Most offer online submission, but you may need to print and mail it.

You'll likely need to include:

Your insurance policy, member, or group number
Name of the patient (you, your child, etc.)
If you have another insurance plan (dual coverage)
Why did you get the treatment (injury, illness, check-up, etc.)

Special cases: If your injury happened at work, in a car accident, or due to someone else's negligence, talk to HR or a legal professional—these situations often involve different insurance processes.

2. Include an Itemized Bill and Receipts

Ask your provider for a detailed bill listing every service, like:

Exams, lab tests, or X-rays
Medications
Surgery or procedures
Equipment (like crutches or braces)

Make sure each item has an ICD-10 code (the diagnosis/treatment code used for billing).

3. Make Copies of Everything

Keep digital or physical copies of:

The claim form
Itemized bills
Any receipts or records

Stay organized! Claims can get lost or denied, and having your paperwork ready makes appeals easier.

What Do I Do if My Claim Is Denied?

Don’t panic, this happens often! First, review the Explanation of Benefits (EOB) to understand the reason for denial. Common reasons include:

Coding errors: If the procedure doesn’t match the diagnosis code.
Missing prior authorization: Needed for certain treatments or procedures.
Incomplete paperwork: Missing medical notes or details.
"Not medically necessary": Insurance says the treatment wasn’t required.
Not covered by your plan: Always check what your plan includes.

Steps to Take:

Call your insurance company and ask why it was denied.
Keep records of all conversations (date, time, name of person, call reference number).
Gather all your paperwork (bills, records, prior authorizations, etc.).
File an appeal. Your insurance company has a process and timeline for this.

If the issue is about medical necessity, ask your doctor to request a peer-to-peer review. This lets your doctor speak directly with the insurance company’s medical reviewer to explain why the treatment was necessary.

Tip:

Act quickly. Appeals often have tight deadlines. Staying organized and asking questions is key to getting claims approved.

Need Help?

Contact your insurer’s customer service team
Speak to your Human Resources department (if you’re on employer insurance)
Use your state’s health insurance navigator or consumer assistance programs

Health insurance is complicated, so don't be afraid to ask for help. This guide is a starting point to help you feel more confident, ask the right questions, and take charge of your health. Like all our resources, please submit a contact form if we missed something you'd like to see!

Glossary: Health Insurance Words You Should Know

Term

What it means

Example

Coinsurance

Copay

Deductible

EOB (Explanation of Benefits)

FSA (Flexible Spending Account)

Group #

HSA (Health Savings Account)

In-Network

Medicaid

Out-of-Network

Out-of-Pocket Maximum

A percentage you pay after meeting your deductible.

A small fee you pay each time you visit the doctor or get medicine.

The total you pay out of pocket before insurance helps. Copays and premiums do NOT count towards your deductible.

A summary of what your insurance paid and what you might owe.

Similar to an HSA but often "use it or lose it" by year-end. Available through employer-based plans.

Your employer’s plan number.

A savings account for medical costs (used with high-deductible plans).

Cheaper care with doctors who work with your insurance.

Government insurance for people who don’t make a lot of money.

You can still go, but you’ll pay more.

The most you’ll pay in a year. After that, insurance pays 100%.

Policy # / Member ID

Premium

Prior Authorizations

Referrals

RxBIN

Secondary Insurance

Your unique plan number.

The monthly cost of having insurance (like a subscription).

Your provider must get approval from your insurer for high-cost or specialty services. Without it, the service may not be covered.

Your PCP refers you to a specialist. Often required by HMO and POS plans.

A code that helps pharmacies send your prescription claim to the right place.

Backup plan to help cover more costs.

You pay 20%, insurance pays 80%.

$20 when you visit your doctor.

You pay the first $2,000 in medical bills.

Not a bill, just info. You see your doctor charged $100, insurance paid $80, and you owe $20.

You set aside $500 to pay for contacts or co-pays during the year.

Listed on your insurance card if you get coverage through work.

You use it to pay for a $50 prescription with pre-tax dollars.

A check-up with an in-network doctor costs $30 instead of $80.

You qualify based on income and apply through your state’s website.

You see a specialist not covered and pay the full $200 yourself.

Your plan has a $6,350 out-of-pocket max. After paying $2,000 in deductible and $3,150 in coinsurance throughout the year, you reach $6,350. From then on, insurance covers all approved costs for the rest of the year.

Used when filling out medical forms or calling your insurer.

Your insurance costs $150/month.

Your doctor needs approval before an MRI is scheduled.

You need a referral from your doctor to see a dermatologist.

The pharmacist uses the RxBIN from your card to process your prescription.

Medicare is your primary insurance, and a retiree plan from your old job is secondary.

Frequently Asked Questions

What’s an Explanation of Benefits (EOB)?

An EOB is a summary of how your claim was handled. It tells you:

What was billed
What your insurer paid
What you still owe

Tip: An EOB is not a bill, but review it carefully to ensure accuracy.

What’s Covered by Insurance?

Plans differ, but many include:

Preventive care (e.g., vaccines, screenings)
Emergency services
Hospital and outpatient care
Mental health services
Maternity and newborn care
Prescription drugs
Check your plan documents for:
- Dental and vision (often separate)
- Mental health coverage details
- Coverage for pre-existing conditions (protected under the ACA)

Are Prescription Drugs Covered?

Yes, but coverage varies. Plans use formularies (lists of covered drugs):

Tier 1: Generic, lowest copay
Tier 2: Preferred brand-name, mid-range cost
Tier 3: Non-preferred, higher cost
Specialty Tier: Expensive or rare-use drugs
Find your plan’s formulary online.

What About International Travel?

Most basic U.S. health plans don’t cover international care. If you're traveling abroad:

Look into travel insurance or an international plan.
Some schools offer student travel insurance for study abroad.

When Do You Age Out of Your Guardian's Insurance

Most plans stop covering you on your 26th birthday. You have 60 days after that to get your own plan.

Exceptions:

Some states (like NY and FL) may allow coverage until 30.
If you have a disability, you might be able to stay on longer. Check with your insurer.

What Happens in an Emergency?

If you’re traveling in another state and have a serious medical emergency, you’ll be taken to the nearest hospital, even if it’s not in your insurance network. Federal law requires that this care be billed as in-network to ensure access to life-saving treatment.

However, insurance companies may define “emergency” differently. In some cases, they might deny your claim if they decide your situation wasn’t a true emergency. In this case, you can appeal the denial. It might be time-consuming, but it’s worth doing, especially if you're facing a high out-of-network bill.

Can I Use My Insurance in Another State?

Yes, but it depends on your plan.
- PPO/OAP: Usually works across states, so check to see if your provider is in-network nationally.
- HMO/POS/EPO: Most out-of-state care is considered out-of-network (not covered unless it’s an emergency).

Always check with your insurer before you go.

I'm Moving to Another State, What Does that Mean?

If you move to a different state:

Marketplace plans: You’ll need to re-apply through your new state’s exchange.
Employer plans: Ask HR if your plan offers coverage in the new state.
Medicaid: You must reapply in your new state because eligibility rules vary.
COBRA: You might be able to keep your plan temporarily, but check with your benefits office.

A move typically qualifies as a Special Enrollment Period, so act quickly to avoid a gap in coverage.

Why isn’t Dental and Vision Included in My Medical Insurance?

Medical Insurance: Covers doctor visits, hospital stays, tests, and more.
Pharmacy Insurance: Covers the cost of medications.
Dental Insurance: Helps pay for dentist visits, braces, cleanings, etc.
Vision Insurance: Helps cover eye exams, glasses, or contacts.

Sometimes these are all bundled into one plan. Other times, dental and vision are separate plans.

Insurance Terms Demystified

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What Is Health Insurance?