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Whether you're purchasing a plan through the Marketplace or from a private insurance company, there are many things to consider when shopping for health coverage. From premiums and deductibles to the services provided, what makes sense for you could be completely different from someone else. We're here to help answer some common questions so you can make a decision about your health insurance with confidence.
Health Insurance Basics
The type of health insurance you need depends on a variety of factors including your medical history, financial status, and family situation. Before settling on a plan, you'll first need to understand the difference between the types of policies, coverage levels, and networks options that are offered.
At a broad level, there are 3 primary types of health insurance policies—major medical, short-term, and catastrophic.
Major medical insurance in the most common and comprehensive type of insurance. It's available year-round to help you pay for both routine care and serious conditions. These plans have a yearly out-of-pocket maximum and are legally required to offer minimum levels of coverage for all the major healthcare categories such as preventive services, prescription drugs, hospitalization, maternity care, and rehab services.
Short-term health insurance offers significantly lower prices than major medical and allows you to enroll for less than a year at a time. However, these plans usually cover far fewer services and don't insure people with preexisting conditions. They also typically limit the amount of coverage, so you'll be required to foot the rest of the bill if you reach your maximum. Some plans even put a limit on how much they're willing to pay for each day of care.
Catastrophic health insurance is low-cost coverage designed for individuals under 30 or those who show they're unable to afford another plan. These have the lowest monthly premiums, but very high deductibles—$7,900 as of 2019. However, benefits include certain preventive services at no cost and at least 3 primary care visits per year. If you do reach your deductible, your insurance will pay for 100% of all covered services.
Amount of coverage
The next step to choosing the right insurance is to understand the different coverage that's available. While catastrophic insurance only covers preventive and primary care services, the benefits of short-term insurance can vary widely by the state, the company, and the specifics of the plan. It's important to compare these benefits and read the fine print when shopping for one of these plans.
If you're looking for major medical, however, it's easier to understand the coverage you'll receive based on the tier of your plan. In general, these policies are broken into 4 primary "metal" categories—Bronze, Silver, Gold, and Platinum. Beyond providing certain preventive services at no cost to you, each category pays a certain percentage of your medical costs once you've paid your deductible. The more expensive your monthly premium, the lower your deductible and the higher percentage your plan will pay.
Although the exact level of coverage varies depending on your policy, the metal levels typically follow these general guidelines:
|Metal Level||Monthly Premium||After Your Deductible, Your Plan Covers...||And You Pay...|
Networks and providers
Beyond the benefit level, another factor to consider is the type of network your plan offers. A network is the group of providers, hospitals, and clinics your insurance works with to provide healthcare services at a discounted rate.
Health insurance plans are designed to fit different types of networks. Many plans incentivize you to receive care from providers that are "in network," while others give you more flexibility for where you receive care. While shopping for health insurance, you might come across any or all of these types of plans at the various metal levels:
- Exclusive Provider Organization (EPO): Only covers services that are in the plan's network, except in an emergency
- Health Maintenance Organization (HMO): Usually restricts your options to providers in the HMO network within a specific service area and won't cover out-of-network services except in an emergency
- Point of Service (POS): Pays more for services offered by in-network providers, but requires that you get a referral from a primary care doctor in order to see a specialist
- Preferred Provider Organization (PPO): Covers a larger percentage of costs for in-network providers, but charges an additional fee for using a physician or hospital out of the network, with or without referral
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