Health insurance generally covers:

• Doctor visits
• Hospital visits
• Outpatient care
• Preventive coverage, such as annual physicals
• Prescription drugs
• Labs and tests

What Does Health Insurance Not Cover?

The extent of coverage provided by health insurance plans varies depending on the plan type and the insurance company. There are some services that may not be covered at all, while others may only be partially covered. Some common examples of services that health insurance may not cover include cosmetic procedures, experimental treatments, alternative therapies, and certain elective surgeries. It is important to review your policy carefully to understand what services are covered and what additional expenses you may need to pay out-of-pocket.

For instance:

• Care received outside of your provider network will not be covered by a health maintenance organization (HMO) or exclusive provider organization (EPO) plan.
• A preferred provider organization (PPO) will cover out-of-network treatment, but at a reduced rate compared to in-network care. As a result, you, as a member, will be responsible for a higher portion of the out-of-network treatment expenses.

Here are examples of what a health insurance plan may not cover:

• Out-of-network care
• Cosmetic surgery
• Some prescription drugs
• Fertility care
• Experimental treatments and drugs

Ways to Get Health Insurance

For many pre-retirement Americans, employer-sponsored health insurance is a common way to access healthcare coverage. Individuals under the age of 26 may also be eligible for health insurance through various means such as an employer, spouse’s plan, or parent’s health plan. However, it is important to note that once an individual reaches retirement age, they may need to explore alternative options for healthcare coverage such as Medicare or private insurance plans. Additionally, it is always advisable to carefully review policy details and coverage options before selecting a healthcare plan.

From an Employer

The majority of pre-retirement age Americans obtain health insurance through their employer, as it is often provided as part of their benefits package. This group coverage is generally more cost-effective compared to other options, as employers commonly cover over half of the expenses.

Affordable Care Act Health Insurance Marketplace

The health insurance marketplace at Healthcare.gov provides coverage for individuals who are not eligible for an employer-sponsored health plan. While some states have their own exchange websites, Healthcare.gov can direct you to the appropriate exchange for your state. Both the federal marketplace and state exchanges enable you to compare available plans in your location by entering your income and family details. The marketplace website utilizes your income to estimate costs for each plan, taking into account subsidies and premium tax credits that lower ACA plan expenses.

Directly from a Health Insurance Company

You have the option to purchase a personal health insurance plan directly from an insurance company without using the federal marketplace website. These plans may be identical to those available on the ACA exchange. If you choose this option, you will not qualify for the subsidies provided with ACA plans. Insurance companies may also offer plans that are not available on the ACA exchange and do not adhere to federal regulations. While you may find a more affordable plan directly from an insurer, it may not offer the same level of coverage as the plans available on the federal health insurance marketplace.

Medicare

Medicare is a federal health insurance program that covers senior citizens, certain individuals with disabilities, and those with end-stage renal disease. It consists of various parts such as Original Medicare (Parts A and B), Medicare Advantage (Part C), and Medicare Part D.

• Part A covers hospitalizations, skilled nursing facilities and hospice care.
• Part B covers doctor services, outpatient care, preventive services and medical supplies.

Members enrolled in both Parts A and B have the option to purchase a Part D plan, which includes prescription drug coverage. Medigap plans help fill in the gaps in Medicare coverage. Another option is Medicare Advantage, provided by private health insurance companies, which offers benefits from Parts A and B as well as typically including prescription drug coverage. Medicare Advantage plans often include additional benefits such as dental care, vision care, and assistance with meal and transportation costs.

Medicaid

Medicaid is a health insurance program for low-income individuals that is operated by the federal and state governments. Eligibility is determined on a state-by-state basis, and the program’s costs are income-based, allowing eligible individuals to access comprehensive health coverage at little to no cost. In addition, the Children’s Health Insurance Program (CHIP) serves as a comparable program for pregnant women and children, with some states opting to integrate CHIP with Medicaid and others maintaining them as distinct initiatives.

Short-Term Health Insurance

Short-term health insurance provides limited coverage at a low cost in many states, but some states prohibit it and critics argue that these plans offer insufficient coverage. These plans are designed to serve as a temporary solution, such as during job transitions. While most states allow insurance companies to offer short-term health plans for up to a year with the option to renew twice, some states impose shorter limits. One downside of short-term health insurance is the less comprehensive coverage compared to standard health insurance, making it challenging to find plans that include maternity care, prescription drugs, and mental health services.

Catastrophic Health Insurance

Individuals under 30 and those facing significant financial hardship, such as homelessness, are eligible for catastrophic health insurance. These plans, provided through the ACA marketplace, feature low premiums and high out-of-pocket costs for medical services. In contrast to short-term health plans with restricted benefits, catastrophic health insurance offers the same level of coverage as an ACA plan.

What Are the Types of Health Insurance Plans?

When it comes to health insurance, there are various types of benefit designs offered by different companies. The type of benefit design you choose can impact several aspects, such as the healthcare providers you can access, the amount you pay for services, and whether or not you need a referral to consult with a specialist. For instance, some plans may require you to get a referral from your primary care physician before seeing a specialist, while others do not have this requirement. It is important to carefully evaluate the benefit designs available to determine which one best suits your healthcare needs and budget.

Preferred Provider Organization (PPO)

Preferred provider organization (PPO) plans are known for their flexibility, which often comes at a higher premium than other plan types. With a PPO, you have the freedom to seek out-of-network care, but this comes at a higher cost than in-network care. However, you do not need a referral from a primary care provider to see specialists under this type of plan. It is important to note that while PPOs may offer more flexibility, they may not always be the best option for everyone. The higher premiums can make it difficult for some individuals and families to afford. Additionally, seeking out-of-network care can result in significant additional costs that are not covered by the insurance plan. It is essential to carefully consider your healthcare needs and budget before selecting a PPO or any other type of health insurance plan.

Health Maintenance Organization (HMO)

Choosing between a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO) plan can be a challenging task. However, it is important to note that HMO plans are generally cheaper than PPOs, but they come with more restrictions. With an HMO plan, you are required to designate a primary care provider who oversees your healthcare needs and provides referrals for you to see specialists. Additionally, if you seek out-of-network care, your HMO plan will not cover the cost. It is essential to understand these limitations when considering an HMO plan. On the other hand, PPO plans tend to be more expensive but provide greater flexibility in terms of choosing doctors and accessing care. Ultimately, the decision on which plan to choose should depend on your individual health needs and preferences.

Exclusive Provider Organization (EPO)

Exclusive Provider Organization (EPO) plans are health insurance policies that operate similarly to Health Maintenance Organizations (HMOs) in terms of cost. EPOs do not offer reimbursement for out-of-network care, making it important to stay within the designated provider network. However, unlike HMOs, EPOs do not require a referral from a primary care physician to see a specialist. This can be beneficial for patients who require specialized care or have ongoing medical conditions that require regular visits to specialists.

Point of Service (POS)

Point of service (POS) plans are a hybrid health plan type that incorporates features of both HMO and PPO plans. POS plans generally provide coverage for out-of-network care, similar to PPOs, but require members to select a primary care provider who will provide referrals to specialists, which is more akin to an HMO. Though POS plans are less common than other types of health plans, they can be a good option for those seeking flexibility in their healthcare choices while still maintaining a degree of cost control. It’s important to carefully review the details of any POS plan before enrolling to ensure it meets your specific healthcare needs.

ACA Marketplace Costs by Plan Type

Type Of Plan	Average Monthly Cost For 30-Year-Old	Average Monthly Cost For 40-Year-Old	Average Monthly Cost For 50-Year-Old	Average Monthly Cost For 60-Year-Old
HMO	$427	$480	$671	$1,017
EPO	$466	$524	$733	$1,109
PPO	$512	$576	$805	$1,224
POS	$539	$607	$849	$1,290

How to Choose the Best Health Insurance for You