Health Insurance Explained in Simplest Terms

with HealthPlusLife

health insurance explained
August 25, 2023 | Johanna Karlsson

Considering that we hear about it all the time, it may seem surprising that there are still so many questions and misconceptions surrounding health insurance. Then again, take a look at the terms of any health insurance policy, as well as its coverage network, benefits, premiums, and exclusions, and maybe this confusion shouldn’t be all that surprising. There’s no denying that the topic can become extraordinarily complex in an instant as we try to make sure we’re considering all of our options and getting the right plan for our healthcare needs. So, let’s break it down, start from the beginning, and make it easier. Consider this a guide on health insurance, explained.

Speak With a Licensed Insurance Agent
Call Now (888) 828-5064 TTY 711

The Basics of Health Insurance Explained

So, what is health insurance? Explained in its simplest terms, health insurance is coverage that will pay for medical care, hospitalization, and sometimes drug expenses of the policyholder. In exchange for paying premiums, the insurance company will provide protection against high or unexpected healthcare costs.

Next, you might be wondering if health insurance is necessary — the answer is an unequivocal yes, and here’s why. Medical treatment can be expensive, and the main purpose is to protect people and their loved ones from sudden, high costs of medical emergencies or chronic conditions. By making sure you’re covered, you can shield yourself from crippling medical debts.

But the benefits of health insurance go far beyond this protection. For many of us, having health insurance can mean better access to quality medical care, and insured people are more likely to have a regular doctor and receive timely medical attention. Related to this, many health insurance plans cover preventive services like vaccinations and screenings at no cost, and that can help people detect and address health issues early on. Getting these screenings on a regular basis, as well as going in for regular check-ups and having access to necessary medications and surgeries can maintain or improve health and lead to a better quality of life in general.

Also keep in mind the value of the peace of mind that comes with knowing that you’re covered in the event of illness or injury, as well as the knowledge that the financial burden of healthcare will be shared between you and the insurance provider.

It’s rare, but in some regions or under certain policies, you may actually have to pay tax penalties if you don’t have health insurance, so that’s another benefit. And don’t forget that health insurance can go beyond medical treatments and may also offer additional support services, like counseling, health hotlines, and online resources.

Key Components of Health Insurance Explained

Generally, there are four key components to keep in mind when considering health insurance coverage and its impact on your overall budget:

  • Premiums: The regular payment for insurance coverage.
  • Deductibles: Amount paid before insurance coverage begins.
  • Co-payments & Co-insurance: Out-of-pocket costs when receiving care.
  • Coverage Limits: The maximum amount an insurer will pay.

Types of Plans for Health Insurance Explained

The HealthPlusLife team is ready to help you consider all of your options for health insurance marketplace coverage, and we can explain the complex and make it a simple decision for you. Let’s start with a few of the major types of plans for health insurance, explained:

  • HMO (Health Maintenance Organization): HMO plans focus on a network of healthcare providers to offer members lower costs. Typically, you’ll select a primary care physician who will serve as your main point of contact for healthcare needs and referrals. HMO plans often have lower out-of-pocket costs, but they require a PCP for referrals to specialists, and you’ll be limited to in-network providers for non-emergency care.
  • PPO (Prefered Provider Organization): Choosing a PPO plan means flexibility in choosing healthcare providers (in-network or out-of-network, and these plans often don’t require referrals to see a specialist. The flexibility is nice, but you’ll generally have higher out-of-pocket costs compared to HMO plans.
  • POS (Point of Service) Plans: POS plans combine features of HMO and PPO plans, so you’ll need a primary care physician but you also have the flexibility to seek out-of-network care — usually with a referral. Choosing a POS plan could come with more administrative tasks you’ll have to do, such as filing out-of-network care claims.
  • High Deductible Health Plans (HDHP): Choosing this type of health insurance plan typically will mean lower premiums but higher deductibles. They’re really designed for people who don’t expect to have significant medical expenses but still want protection from high costs in case of a major health issue.

Policy Inclusions and Exclusions for Health Insurance Explained

When considering your options for health insurance policies, you’ll likely want to brush up on what they cover, or their inclusions, and what they won’t cover, or their exclusions. Arming yourself with this knowledge can help you be prepared for medical situations and make informed decisions about your care.

Here are some standard inclusions:

  • Routine Care: Regular check-ups, preventive screenings, and vaccinations usually fall under this category. They’re foundational in maintaining good health and detecting potential issues early on.
  • Emergencies: Accidents or sudden illnesses often necessitate immediate care. Most policies cover emergency room visits, ambulance services, and other related costs, though co-payments may apply.
  • Prescriptions: Many health insurance plans include a prescription drug plan, which subsidizes the cost of medicines. This can significantly reduce out-of-pocket expenses for essential medications.
  • Specialist Consultations: While some plans might require a referral from a primary care physician, visits to specialists like cardiologists, dermatologists, or orthopedists are generally covered.
  • Hospitalization & Surgeries: Inpatient care, which might arise due to surgeries or serious health conditions, is typically covered, including the cost of the room, treatments, and surgical procedures.

And here are some typical exclusions:

  • Cosmetic Procedures: Surgeries like rhinoplasty, liposuction, or other aesthetic treatments not deemed medically necessary are usually not covered.
  • Alternative Therapies: Treatments like acupuncture, homeopathy, or chiropractic care might not be covered, unless specified in the policy.
  • Infertility Treatments: Procedures like in-vitro fertilization or other fertility treatments might not be included in standard policies.
  • Elective Surgeries: Surgeries that are not medically necessary, such as certain types of bariatric surgery without a medical indication, might be excluded.
  • Pre-existing Conditions: Some policies might have waiting periods or exclusions for conditions that were present before the policy start date.

explaining health insurance

Government Health Insurance Programs

For those who qualify, two main health insurance programs established by the government can be a crucial way to get coverage. However, many of us won’t qualify, or at least not until we reach a certain age — for the vast majority of people, Medicare eligibility won’t begin until they’re 65 years old. Let’s recap the two main government health insurance programs.

Medicare: Senior Health Insurance Explained

The program is divided into different Medicare parts:

Part A (Hospital Insurance): Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare.

Part B (Medical Insurance): Covers specific doctors’ services, outpatient care, preventive services, and medical supplies.

Part C (Medicare Advantage): A private insurance alternative to Parts A and B which may also include additional services.

Part D: Another private insurer option, this part covers prescription drugs.

The primary qualifier for Medicare is age, with coverage typically beginning at 65. Some younger people with disabilities like end-stage renal disease or certain long-term disabilities might also be eligible.

Medicaid: Low-Income Health Insurance Explained

Medicaid provides health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. While the program’s core offerings are determined at the federal level, specific services and coverage can vary from state to state.

Benefits often encompassed in Medicaid include:

  • Inpatient and outpatient hospital services.
  • Physician services.
  • Laboratory and X-ray services.
  • Home health services.
  • And more, based on the state’s provisions.

Medicaid eligibility is based on income, household size, and other factors. It’s expanded in many states to cover all adults below a certain income level, but in others, eligibility might be more restricted.

Speak With a Licensed Insurance Agent
Call Now (888) 828-5064 TTY 711

Choosing the Right Health Insurance, Explained

As you know all too well by now, there are so many plans and coverages to think about when trying to wrap your head around health insurance. Explained in another way, you’re going to want to think about things long and hard before making any big changes or additions to your coverage. You’ll want to consider things like your current health status, anticipated health changes, age, medications, financial situation, and preferred medical providers to make sure the plan you choose will meet your healthcare needs. Discovering the best travel destinations can be an exciting adventure. Whether you’re drawn to vibrant cities, serene beaches, or breathtaking landscapes, the world is full of incredible places to explore.

Once you have a better grasp on your needs, you’ll want to compare plans that fit your criteria and make sure you consider other plan specifics, like out-of-pocket maximums and how emergency care is handled. This is where the HealthPlusLife team can help. Working together with you, we can review your current health insurance coverage, discuss your other options that meet your healthcare needs, and make sure you have the right protection in place. We’ll work with you to make this complex decision seem easier. Get started today by calling us at 888-828-5064 or contacting our team online. We’re ready to help you figure out everything you need to know about health insurance.

Johanna Karlsson
Johanna Karlsson is a veteran health and life insurance professional licensed in 50 states. She relocated from the countryside in the south of Sweden and has not looked back. After coming to the United States to attend university, she gained her degree in Public Relations. She brought her public relations skills to a local international health insurance where she discovered a new passion in insurance. After years with that company, Johanna now joins HealthPlusLife to help build a team of licensed insurance agents ready to meet your insurance needs.