Insurance is a risk management strategy: basically, a customer pays an insurance agency a fee to "insure" their property and, in exchange, the insurance agency will pay the customer back for any damages that happen to that insured property-- for example, you can pay a monthly fee to a housing insurance agency to insure your house in case of a storm, and if your house is destroyed in a storm, the insurance agency will pay you the price of the entire house. Health insurance is a form of insurance where the property you're paying to insure is your physical and mental health; when you pay for your health insurance every month, your money goes into a large pool that the health insurance agency uses to pay for customers' medical expenses over the course of the year. Health insurance agencies turn a profit when the pool of money they collect from their monthly fees is bigger than the amount of money they pay out to customers.In the United States, we define health insurance as a contract between a person and a health insurance agency-- the contract states that the customer will pay the health insurance agency a monthly fee (a premium) in exchange for the health insurance agency paying some part of that person's healthcare expenses. A health insurance plan or policy is a specific contract that describes the exact amounts that a health insurance company will pay for each of the customer's healthcare expenses when a person signs up for that plan. These plans usually last one year and are renewed annually; January 1st is the most common start date.Insurance agencies' profits increase when they charge higher fees and pay out less. Because health insurance companies are businesses, their goal is to charge as much as they can for their plans and cover as few of their customers' healthcare expenses as possible-- the less expenses they cover, the more money they keep as profit.
Every health insurance plan has a premium-- the amount that you pay, usually monthly, to continue having health insurance. Your premium stays the same every month and doesn't change based on the healthcare services you receive.Throughout the year, as you spend money on your healthcare, your health insurance plan keeps a running total of how much money you've spent. You can divide your year into three phases:
Filling your deductible: Your deductible is the amount of money that you need to pay out of pocket before your health insurance kicks in and starts paying for your care. Until you reach your deductible, you pay for all of your healthcare expenses as though you're uninsured.
Example: At the start of the year, if your deductible is $1,000 and you have an in-network doctor's appointment that costs $100, you will pay the full $100 for your doctor's appointment, your insurance will pay nothing, and you'll have $900 remaining on your deductible. Paying your monthly premium does not count towards filling your deductible; you need to keep doing that regardless.
After reaching your deductible and before reaching your out-of-pocket maximum: Once your deductible is filled, your insurance kicks in and your insurance provider starts to cover their share of your medical expenses. In this phase, you will likely be responsible for covering copays (set fees) and/or coinsurance (percentage fees) on all of your medical expenses.
Example: After you've paid your deductible, you have a doctor's appointment that costs $100. Your insurance has a $20 copay and 10% coinsurance for this type of doctor's appointment. When you go to the doctor, you will pay the $20 copay and the 10% coinsurance ($10), for an out-of-pocket total of $30 for the appointment. Your insurance will pay your doctor's office the other $70.
Hitting the out-of-pocket maximum: Your out-of-pocket maximum is the maximum amount of money that you will have to pay into your health insurance for the year (excluding your premium payments, which don't count towards this number). Once you reach your out-of-pocket maximum, your insurance covers all of your healthcare expenses until the end of the plan year (usually December 31st): you functionally have a $0 copay and 0% coinsurance. You still have to pay your monthly premium, though.
Example: Your out-of-pocket maximum for the year was $5,000; you've reached it by paying your deductible at the start of the year ($1,000) and a mix of copays and coiunsurance ($4,000). It's now October 1st; between now and December 31st, you will pay $0 for any in-network medications and services, so long as you keep paying your monthly premium. On January 1st, your plan resets, and you need to start refilling your deductible from scratch.
Even when you've met your deductible, your health insurance will not apply to every provider, procedure, pharmacy, or medication. Your plan will provide you with a list of providers and clinics that are "in-network," meaning that they have an agreement with the health insurance agency; your health insurance will apply to appointments that are provided by in-network providers, and you can use appointments with these providers to help fill your deductible and out-of-pocket maximum. If a provider or clinic is "out-of-network", your insurance may not provide any coverage for the appointment, or may provide less coverage than they would for an in-network provider; out-of-network payments will most likely not contribute to your deductible or out-of-pocket maximum. In general, you save the most money by seeing providers that are in-network, so it's important to check that any providers you intend to see routinely are covered by your insurance plan.Health insurance companies also offer a formulary, which is a list of all medications covered by the insurance plan. Formularies are sorted into price tiers, with brand-name and specialized medications in the more expensive formulary tiers. Your plan will then charge you a copayment associated with the medication's tier every time you fill a prescription. Paying for covered medications may contribute to your deductible and out-of-pocket maximum. When choosing a new plan, be sure to read the formulary carefully to see how much you will be paying for each of your medications-- the same medication may show up in multiple formulary tiers based on its concentration, dose, and route of administration.Not every health insurance policy is required to cover every type of care-- for example, transgender healthcare, abortion access, or substance use disorder services may not be covered by every insurer or plan. Before purchasing a new plan, be sure to read through its documentation carefully to ensure that the services you need are covered.
Plan/Policy
The exact agreement that you have made with your health insurance company; your plan is a contract that describes how much you and the insurance agency will each pay towards the different aspects of your medical care. Generally, your plan will require you to pay a monthly fee (your premium) to continue receiving coverage and will describe how much you need to pay (copayments/coinsurance) for each type of service you receive. Individual insurance agencies usually offer several different plans with different fees.Consumer
The person receiving health insurance and healthcare. That's you!Provider
Any healthcare worker that you see-- your doctors, nurses, physician assistants, psychiatrists, psychologists, physical therapists, doulas, substance use counselors, and everyone else on your healthcare team. Every insurance agency will have a list of "in-network" providers that they maintain contracts with.Primary care provider (PCP)
A doctor, nurse, or physician's assistant who provides and coordinates a consumer's healthcare. Your PCP is your point of contact for accessing healthcare; many health insurance plans will require you to designate a PCP who will provide your generalist care. If your plan requires a referral before you can seek specialized care, your PCP will be your referring provider-- they'll give you an initial evaluation and then pass you to the specialist.Referral
A written order from your primary care provider for you to see a specialist or receive specific medical services. Some plans, particularly Health Maintenance Organizations (HMOs) and Point of Service (POS) plans, may require a referral from your PCP before covering care from any other provider.In-network
A provider/clinic/hospital/pharmacy that has signed a contract with a health insurance company; generally, the provider will charge the company less for their services in return for the company encouraging its consumers to see that provider via low prices. If a provider is in-network, you will only need to pay a copay/coinsurance to see them as opposed to an out-of-network provider, where you would need to pay for the full price of services yourself. A provider that is in-network with a specific insurance agency will not necessarily be in-network for every plan that agency provides.Out-of-network
A provider/clinic/hospital/pharmacy that has not signed a contract with a health insurance company; you will usually need to pay the provider's full out-of-pocket cost unless your plan specifically offers some form of coverage for out-of-network providers. Out-of-network emergency care is the exception; most plans will offer some form of coverage for emergency care (like ambulance fees and ER expenses) provided out-of-network.Claim
A request for payment that you or your provider submit to your insurance company; the insurance company can then either pay for the medication/service or deny the claim, in which case you will need to pay out of pocket. If your insurance company denies a claim for a medication or service that you think should be covered by your plan, you can contest the denial.Formulary
An insurance agency's list of medications that they will cover. Available publicly through your insurance provider's website. Medications are usually priced in "tiers", with common medications and generic medications generally falling in the less expensive tiers. Pay very close attention when checking the price tiers of your medications-- small differences in medication concentration, dosage, or route may dramatically change their prices.Premium
The fixed amount of money you pay each month to maintain your health insurance. Your premium is determined by the number of people covered on your plan, your age, your location, and whether you use tobacco. Health insurance companies used to be able to charge a higher premium if you have a preexisting health condition that might lead to higher medical expenses; new plans can no longer do this, but some older plans that have been grandfathered into the current system still can.Deductible
The amount of money that you pay out of pocket on your healthcare every year before your health insurance kicks in; usually, a plan with a high premium will have a low deductible and vice versa. $0 deductible plans usually have very high premiums, but make up for it by skipping the deductible-- you start receiving coverage for your services immediately at the start of the year.Copay
A flat amount of money that you pay out of pocket for a specific service or medication; a $0 copay means that you won't pay out of pocket for a service once your deductible is met.Coinsurance
The percentage cost that you pay out of pocket for a specific service or medication. Some plans list services as having a 100% coinsurance, which means that insurance will not cover that service at all until the out-of-pocket maximum is reached.Out-of-pocket maximum
The maximum amount of money that you pay for medical care before your insurance covers the rest. Includes your deductible, copayments for in-network medications and services, and coinsurance for in-network medications and services. Does not include your premium or any out-of-network payments.HMO (Health Maintenance Organization)
A type of health insurance plan with low premiums and low out-of-pocket costs, with the tradeoff that the consumer is limited to a small, local network of providers; providers can charge reduced rates to HMOs because they know that they will get a lot of appointments in the smaller network. HMOs require consumers to get a referral from their PCP if they need to see a specialist, which can be expensive and time-consuming for people with complex or new health conditions.PPO (Preferred Provider Organization)
A type of health insurance plan where the consumer is allowed to see specialists both in- and out-of-network without a referral, with the tradeoff that these plans have higher premiums, deductibles, and out-of-pocket costs. PPOs follow a similar business model to HMOs (providers charging the insurance companies less in exchange for lots of appointment bookings), but are more flexible-- consumers get better rates when they see in-network providers.EPO (Exclusive Provider Organization)
A type of health insurance plan that splits the difference between an HMO and a PPO-- it allows for consumers to make specialist appointments without consulting their PCP, but does not provide any out-of-network coverage.POS (Point of Service)
A type of health insurance plan that is the polar opposite of an EPO-- consumers can receive some coverage for out-of-network providers, but they need a referral from their PCP in order to see a specialist. Not a common type of plan.HDHP (High-Deductible Health Plan)
A health insurance plan with a very low premium and a very high deductible-- the idea is that the plan will be incredibly cheap in exchange for very little coverage outside of major emergencies. Also called "catastrophic" health insurance plans because the insurance only kicks in if there is a catastrophe large enough to burn through the deductible. Often used as a backup plan for consumers who mainly use an HSA to pay for their healthcare, just in case something goes terribly wrong.HSA (Health Savings Account)
A tax-advantaged personal savings account designed to be used for paying your healthcare expenses; if you don't spend the money that you store in your HSA on healthcare, it garners interest and rolls over into the next year. Basically, instead of paying for health insurance, your HSA allows you to deposit the cash you'd ordinarily pay on your premium into an untaxed bank account until you need it to pay for your medical care. Money can be removed from the account specifically to pay for medical expenses not covered by insurance, which is why HSAs tend to pair well with High-Deductible Health Plans, which are known for not covering much.
Your employerIf you work at least thirty hours a week for a business, your employer is required by the Affordable Care Act to provide you with a health insurance option that meets federal essential coverage standards (including preventive care, emergency services, and prescription medications). This health insurance must be "affordable;" your employer is required to pay part of the plan's monthly premium in order to ensure that your contribution stays below a certain percentage of your income.While there isn't a set percentage that your employer needs to pay into your employee health plan, many employers cover 50% to 80% of the premium for individual coverage; this usually doesn't extend to dependents, so adding a spouse or child to your plan may dramatically raise your premium.Your spouse or parentIf your spouse or parent has a health insurance plan, you may qualify for coverage under their health insurance plan as their dependent; this means that they will pay extra on their premium to cover you. Being someone's medical insurance dependent is unrelated to being their tax dependent; you can be both, only one, or neither.For spouses: Legal marriages are always recognized by health insurance, while common-law and domestic partnerships may or may not be recognized; common-law and domestic partnerships are most likely to be recognized by employer health plans than by Marketplace or off-exchange plans.For children: You must be the legal child (biological, step, adopted, or foster) of the parent with the insurance plan. The Affordable Care Act allows you to remain on your parent’s health insurance plan until age 26, regardless of whether you are married, financially dependent on the parent, or enrolled in school.Military plans: TRICARE, Veterans Affairs, and CHAMPVATRICARE is the healthcare program for the US Department of Defense service members and their dependents, while the US Department of Veterans Affairs manages healthcare programs for US veterans and their dependents; the VA manages its own integrated healthcare system containing outpatient clinics, hospitals, medical centers, and long-term healthcare facilities.CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs) provides health coverage to some spouses and dependent children of service members with permanent service-connected disabilities; these benefits may persist after the disabled service member's death.TRICARE, the VA, and CHAMPVA provide insurance plans that are generally designed to be used at military hospitals and clinics. As a service member transitions out of active service, they can receive assistance in transitioning from TRICARE onto VA benefits through the Department of Veterans Affairs website, VA.gov.Federal plans: Medicare, Medicaid, and CHIPMedicare
Medicare is a federal health insurance program for people who are 65 and over; a few disabled individuals with high support needs may be able to access their Medicare benefits sooner.Medicare coverage is broken down into four "parts":
- Part A is specialty insurance for hospitalizations, home or skilled nursing, and hospice
- Part B is the main medical insurance
- Part C, or Medicare Advantage Plans, are a separate form of private hospital and medical insurance that can replace Parts A and B
- Part D is optional mediation insurance designed to fill gaps in parts A, B, and CGenerally, a person on Medicare will sign up for Parts A and B when they start receiving Social Security benefits. If they'd like, they can swap their Medicare Part A and B coverage for a Part C plan; in general, Part C plans tend to be cheaper than A and B for very healthy people, but become more expensive quickly when you get sick or need emergency care. Part D can be added onto any of the other three parts as a supplementary policy. Medicare.gov has additional information about when you should register for Medicare based on your age, health situation, and when you would like to start collecting Social Security.Only US citizens and some documented immigrants can receive Medicare.Medicaid
Medicaid provides free or low-cost health insurance plans to the following groups of people:
- Pregnant individuals
- Low-income adults aged 18-64
- Children
- People aged 65+
- People with disabilities
- Some federally-recognized tribesMedicaid funding comes from both the federal and state governments, and it works differently in every state; in North Carolina, Medicaid provides you a marketplace of potential plans and allows you to choose which one works best for you. If you think you might be eligible for Medicaid, you should find your state's Medicaid website through Medicaid.gov and check; Medicaid plans will often be your most affordable options if you qualify. You can also call your state's Medicaid office for more help.If you decide to go through the Health Insurance Marketplace, your intake form is also a Medicaid screener. If it looks like you might qualify, your information will be automatically passed on to your state's Medicaid office and they'll reach out to you.Only US citizens and some documented immigrants can receive Medicaid. If you've aged out of foster care in the US and are under the age of 26, you qualify for Medicaid automatically, regardless of your income.CHIP
CHIP is the Children's Health Insurance Program; it provides medical and dental insurance plans to children under the age of 18 whose families might make too much money to qualify for Medicaid. CHIP functions very similarly to Medicaid (different states can set different requirements for qualification and offer different plans), and in most states CHIP is managed through the Medicaid office. In general, families with combined incomes under $80,000 a year should look into their state's CHIP coverage via the Medicaid.gov website-- if you qualify, this will likely be the most affordable health insurance plan for your children.Marketplace plans
The Health Insurance Marketplace is a service run by the federal government that helps connect people to health insurance plans. The Marketplace offers a selection of Affordable Care Act-compliant plans as well as a list of tools to help customers compare different coverage options-- the Marketplace has a specialized search feature that allow consumers to sort insurance plans by which providers, medications, and services they cover. Open enrollment (the period of time where you can apply for a new insurance plan or switch insurance plans through the Marketplace) starts on November 1st and closes on January 15th; coverage begins on January 1st for people who enroll by December 15th and February 1st for people who enroll after. In order to qualify for a Marketplace plan, you must live in the US, be a US citizen or lawfully-present noncitizen, and not be incarcerated. You can't enroll in a Marketplace plan if you're already on Medicare.Depending on your household's expected income, you may qualify for a lower cost on your Marketplace insurance plan due to a number of cost-savings options and credits, which will be applied automatically to your Marketplace account--individuals that received an insurance option through their employers and high-income households have access to fewer credits. While there were several cost-reducing benefits added to the Marketplace over COVID to help consumers afford healthcare over the pandemic, as of the time of this article's writing (11/15/2025), they have not been renewed for 2026, which means that most Marketplace plans will become significantly more expensive beginning in 2026.In order to apply for a Marketplace plan, you can make an account through this Healthcare.gov link. When you fill in the information to create your account, you will automatically be screened for Medicaid and CHIP eligibility; your state's Medicaid office will reach out to you if you qualify for coverage.To help consumers identify appropriate plans, the Marketplace has four different labels for their health plans called the "metal levels": bronze, silver, gold, and platinum. Higher metal levels (gold, platinum) indicate that plans have low copays/coinsurance and low deductibles in exchange for high monthly premiums, while lower metal levels (bronze, silver) indicate that plans have high copays/coinsurance and high deductibles in exchange for low monthly premiums.Some states allow for a fifth category of Marketplace plan called a "catastrophic" plan, which are only available to consumers who are under 30, qualify for a hardship exemption, or don't qualify for any savings on a Marketplace plan. Catastrophic plans tend to be High-Deductible Health Plans (HDHPs), which have extremely low premiums and extremely high deductibles.Off-exchange plansHealth insurance plans can be purchased directly from private health insurance companies without the Marketplace. These plans are still required by the Affordable Care Act to provide some minimum levels of care, but off-exchange plans have weaker consumer protections compared to Marketplace plans.Because the Marketplace offers so many subsidies and credits to consumers, there are very few times when an off-exchange plan would be more cost effective than a Marketplace plan; if you make enough money to not qualify for Marketplace subsidies, have an employer that will reimburse you for an off-Marketplace plan, have very specific insurance needs that are poorly matched by existing Marketplace plans, or missed the Open Enrollment window and still need coverage, an off-exchange plan may work best for you.
Open enrollment
Open enrollment is the main opportunity to select your insurance plan for the next calendar year. If your current health insurance plan works well for you, this is also when you confirm that you will be re-enrolling in the same plan for the new year. Health insurance companies may dramatically alter their plans each year before open enrollment, so be sure to read over any changes in your policy before re-enrolling.If you receive health insurance options through your employer, the open enrollment period will likely occur sometime in the fall and will often close before the Marketplace opens (November 1st); this means that you may need to decide whether you'd like to accept your employer's insurance plan for the year before you can compare it with the Marketplace offerings.The Affordable Care Act Marketplace's open enrollment window starts on November 1st and ends on January 15th. If you register by December 15th, your health insurance will begin next year on January 1st. If you miss the December 15th deadline, you can still enroll by January 15th for coverage beginning February 1st, leaving you uninsured for the first month of the new year.You do not need to wait for an open enrollment period to enroll in Medicaid or CHIP; you can enroll in either program at any point in the year and coverage can begin immediately.If you don't enroll in a health insurance plan by February 1st, you still have some options: you can find an off-Marketplace plan or utilize a special enrollment period to start a new insurance plan.Special enrollment
Special enrollment periods are times outside of the open enrollment window where you can enroll in or change your Marketplace coverage due to a major life event that stands to dramatically alter how you access your healthcare. Some examples of qualifying life events include:
- Changes in household size: Marriages, divorces, having/adopting/fostering a child, deaths in the family
- Moving: Changing counties/zipcodes, moving for school or work, entering or leaving a shelter or transitional housing, exiting incarceration
- Loss of existing health insurance: Aging out of CHIP, losing Medicare/Medicaid, losing health insurance through your employer, no longer qualifying for coverage as a dependent on someone else's plan
- Changes in legal status: Gaining federal tribal recognition or US citizenship
- An employer offering you a Health Reimbursement Arrangement (HRA)
- Being affected by a natural disasterMost qualifying events offer you a window in which to change your coverage: you usually have sixty days following the event to apply for a special enrollment period and, depending on the event, may be able to apply up to sixty days beforehand as well. You can see if you qualify for a special enrollment period through the Healthcare.gov screener here; be ready to provide documentation about your qualifying event when you apply.You can file an appeal if your initial request for a special enrollment period was denied.COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows some consumers who are insured through their employer to maintain their health insurance plan if they lose their benefits through work (including if they lose their job), with the caveat that the consumer will cover up to 102% of the premium. Because the employer was likely covering a large percentage of the premium before COBRA coverage kicked in, maintaining a plan via COBRA coverage usually means that the consumer pays significantly more out of pocket each month. The biggest advantage to COBRA coverage is that you can continue paying into the same plan-- if you have already filled your deductible and/or out-of-pocket maximum, it may be more cost-effective to pay an increased premium rather than picking a new plan midyear and filling the deductible from scratch.If you have recently lost your insurance through your employer, you may also qualify for a special enrollment period-- it is in your best interests to compare the benefits of extending your current coverage against getting a new Marketplace plan.
NetworkWhen considering a new plan, you should consider the list of in-network providers, facilities, and pharmacies, especially if the plan does not offer coverage for out-of-network services. Are there in-network providers and services close to where you live? Do you travel a lot and need in-network providers in the places where you tend to travel? Do you want a plan that covers your all of your current providers? For plans that require a designated PCP, is there an in-network provider that you trust to coordinate your services? If you need specialty services, are there people in-network that meet your needs?Scope of serviceEvery employer, Medicare, Medicaid, CHIP, and Marketplace plan is required to provide a certain minimum set of services under the Affordable Care Act; the list of required benefits includes emergency room services, doctor and hospital charges, pregnancy services, treatment for all pre-existing conditions, mental health and substance abuse services, lab work, and a list of essential health benefits. Off-exchange plans are held to a lower set of standards and may not cover all of these services. In addition to the ACA requirements, different states may require health insurance plans to cover broader scopes of services, including abortion care and transgender health services. You should read the plan coverage description to see which services the plan will cover-- be sure to keep any specialty services you may need in the coming year in mind as you do.Vision and dental coverage are another major consideration: many health insurance plans do not include vision or dental services, which means that you may either need to purchase separate insurance for these services or pay for them out of pocket.Additionally, some health insurance plans will offer additional covered services as incentives to purchase the plan: yearly no-charge well visits to primary care providers, coverage on certain over-the-counter medications, and coverage to additional services like wellness coaching are common incentives that may factor into your health plan comparisons.MedicationsThe formulary is the list of every medication covered by a plan, sorted into price tiers. When considering a new health insurance plan, you should check the formulary cost for any medications that you know that you'll be using through the year: how much is a refill of your medication? Does the plan cover over-the-counter medications as well? Is there a generic version of your medication in a cheaper tier of the formulary?Yearly costOnce you've narrowed down your list to a few plans, you can compare your estimated yearly costs per plan. Here are some considerations that you should include in your comparisons:
How much is the monthly premium? You will be paying 12 x the premium cost for a year of coverage
How much does a visit to your PCP cost? Your therapist? Your specialists? Are they in-network or will you need to find a new provider? Would you be willing to pay out of pocket for a trusted provider that is out of network? Multiply the copay/coinsurance/out-of-pocket costs that you'd pay each visit by the number of times that you see the provider in an average year
Does the plan include vision and/or dental insurance? How much will you be paying for each of those? If the plan doesn't cover vision and/or dental, how much would it cost to purchase that insurance separately?
How much will your medications cost per year? Check the cost of each of your medications in the formulary and multiply that by the expected number of refills. Be sure to check that your preferred pharmacy is in-network
How often do you need emergency care? Include at least one emergency visit's worth of costs into your estimate, even if you don't wind up in the hospital too often-- if you get into an accident and need to take an ambulance ride, how much would that cost?
Do you have any specialty health expenses coming up, like family planning or cancer treatment? How much will these specialty services cost with the plan?
How quickly will you fill the deductible? Is it worth paying a higher premium in order to get a lower deductible? How likely are you to hit your out-of-pocket maximum?
If you have a list of providers, medications, and services that you need each year, I would recommend estimating the plan's cost for the year by adding together the following:
Premium x 12
For each provider: number of appointments you see them for yearly x cost of an appointment on the plan
For each medication: number of refills you need per year x cost of a refill on the plan
Cost of at least one trip to the ER
Any additional specialty expenses
Be sure to make your calculations with network coverage in mind: if your therapist is not covered by your plan, for example, the cost of an appointment would be their out-of-pocket cost, not the plan's copay/coinsurance for a therapy appointment. Remember that you pay full price on every service until you fill up your deductible with in-network expenses; if your out-of-pocket costs for the year come out to less than the deductible, you should look for a different health insurance plan. If your health costs would fill the out-of-pocket maximum, you can estimate the yearly price of the plan as follows: the out-of-pocket maximum + (12 x the monthly premium).
Find in-network providers
Your insurance agency will have a searchable list of providers, clinics, and pharmacies available via their website-- be sure to double-check that your searches only contain providers who take your specific plan, because not every provider or facility will be in-network for every plan. You can also check provider, clinic, and pharmacy websites for a list of accepted health insurance policies; when in doubt, you can call the provider during business hours and ask if they are in-network for your specific plan.File a health insurance claim
You will most likely not have to file a claim when visiting an in-network provider; the provider will file the claim on your behalf and only charge you for your portion of the bill. If you are visiting an out-of-network provider, receiving reimbursement for a covered medication or service that you paid out of pocket for, or received covered care while out of the country, you may need to file a claim yourself.You can go to your insurance agency's website and search for their online claim filing service to see what they will require in order to file a claim; while the requirements differ by agency, every agency will require a receipt showing how much you paid for your care, so be sure to request an invoice from your out-of-network providers.If your claim is accepted, your insurance agency will pay you back for their portion of your medical expenses.What to do when your claim gets denied:
Health insurance companies frequently reject claims for care that they agreed to cover in the health insurance plan. When your health insurance claim is denied, you have the right to file an appeal, which is a request for another review of your case by the insurance company. Your case rejection should give you a description of your appeal rights and your insurance company will often let you submit appeals via their website.I would strongly recommend seeking professional assistance when crafting your appeal--there are several free and nonprofit services that you can go to for help in appealing your denial, and every state has a Consumer Assistance Program that can help you. In North Carolina, the NC Department of Insurance offers appeals help through the Smart NC program, which can be accessed here.If you want to appeal your denial by yourself, you should consider making a claim file request first; the claim file is a list of all of the materials that your insurance company used in making your denial determination, which you can review for information that you can use in your appeal. ProPublica has a free tool for requesting your claim file from your insurance agency that can be found here.
HealthCare.gov : Home of the Marketplace! Also allows you to check if you qualify for Medicaid, CHIP, or additional savings on your Marketplace plan. Hold onto this link-- you'll need it to update your household and income information throughout the year. Definitely click through the rest of the website if you have the chance; this is where you can find out more about using your coverage, tips to save money on your insurance plan, and all of the odd edge cases that come with insuring a national population.
HealthCare.gov's glossary: A longer list of terms that may come up while you're searching for your health insurance plan; keep this open in another tab while you compare policies!
HHS.gov's explanation of the Affordable Care Act : A quick review of the Affordable Care Act and your protections under it. Includes the full text of the ACA, if you're interested.
USA.gov's health insurance page : Information about how and when to apply for Medicare, Medicaid, and CHIP, as well as additional instructions for navigating the Marketplace.
Medicaid.gov : Your home for all things Medicaid and CHIP! This is very much a policy-focused page, so your best bet for concrete resources surrounding Medicaid and CHIP will be your state's Medicaid homepage. You can find links to those pages here.
Medicare.gov : Your home for all things Medicare! You can apply for Medicare, search for providers, and review the details of your plans through here.
VA.gov's healthcare explanation : Resources for healthcare through the VA! Includes information for people leaving active duty and descriptions of VA benefits.
DoL.gov's COBRA information : The Department of Labor's information page on COBRA and your right to health benefits.
HealthInsurance.org's guide to managed care : A great explanation of the differences between HMOs, PPOs, EPOs, POSs, and using an HSA. If those acronyms still trip you up, there's a great chart comparing and contrasting the different types of plan!
LegalClarity.org's guide to employer health insurance : A quick description of how insurance through your employer works, their obligations to you, and what happens if you lose coverage.
GovFacts.org's guide to Marketplace navigators and brokers : A much more in-depth explanation of the differences between navigators and brokers, including a list of reasons why you might preference one over the other. Very thorough!
BDG's "A terrible guide to the terrible terminology of U.S. Health Insurance" : Much sillier than the other resources on this list, but I had to include it! An internet comedian's very funny and very accessible explanation to the basics of USAmerican health insurance system-- great for people who are intimidated by the amount of acronyms you need to learn to figure out your insurance policy!
https://legalclarity.org/how-does-health-insurance-through-an-employer-work/
https://www.healthcare.gov/lower-costs/
https://www.va.gov/health-care/about-va-health-benefits/
https://www.hhs.gov/healthcare/about-the-aca/index.html
https://www.hhs.gov/answers/medicare-and-medicaid/who-is-eligible-for-medicare/index.html
https://health.mil/Reference-Center/Presentations/2025/03/10/TRICARE-and-Veterans-Affairs-Slides
https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip
https://www.healthcare.gov/see-plans/#/
https://www.usa.gov/cobra-health-insurance
https://www.uhc.com/news-articles/benefits-and-coverage/on-exchange-vs-off-exchange-aca-plans
https://www.investopedia.com/terms/h/hmo.asp
https://www.uhc.com/understanding-health-insurance/types-of-health-insurance/understanding-hmo-ppo-epo-pos/what-is-an-epo
https://www.healthinsurance.org/blog/hmo-ppo-epo-or-pos-choosing-a-managed-care-option/
https://www.chcoc.gov/healthcare-insurance/healthcare/health-savings-accounts/frequently-asked-questions/
https://www.healthinsurance.org/faqs/how-does-a-health-savings-account-hsa-work/
https://www.uhc.com/
https://www.dol.gov/general/topic/health-plans/cobra
https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/
https://www.healthcare.gov/glossary/primary-care-provider/
https://www.healthcare.gov/glossary/referral/
https://www.healthcare.gov/glossary/claim/
https://www.investopedia.com/terms/h/healthinsurance.asp
https://www.ncdoi.gov/consumers/health-insurance/using-health-insurance#MonthlyPremiums-823
https://govfacts.org/government/federal-structure/cabinet-executive-departments/hhs/cms/finding-local-help-navigators-vs-brokers-for-marketplace-enrollment/