Basics of Health Insurance

Health care insurance can be difficult to navigate and understand, even as members of the medical field. There are several different terms to know to make sure you are getting the coverage that you need and understand any hidden costs. We will break down the basics of insurance plans and some of the jargon. Keep these in mind when choosing a plan that works for you and helping your own patients to navigate the system.


  • HMO vs PPO


        • A HMO is a health maintenance organization. This involves coordination between you and a designated primary care provider for most of your care. You will need referrals to see specialists and out of network care is not typically covered by this plan. This type of plan tends to have lower associated costs. Furthermore, because the insurance company works with the in-network providers, they will typically pay directly and filing claims is not necessary.
        • A PPO is a preferred provider organization. In this type of a plan, you can be covered for any provider that you choose, but it will typically cost less to go to a provider in your network. You also do not need a referral to receive coverage for a specialist. While a PPO has more flexibility, it also tends to be more expensive. Going out of network includes a fee and higher deductible, and may also require filing a claim with your insurance company.
        • It is important to consider your lifestyle when choosing a plan that works best. While HMO’s may be less expensive, it may not be suited well for people frequenting going out of their network. Conversely, the flexibility of a PPO may be great for some, but a headache for who can’t find time to file claims.
        • Source:


  • Insurance Jargon Made Easy


      • Deductible: This is the amount you are required to contribute out of pocket before the insurance company will take over the bills. This averages around $1,000 for individual coverage.
      • Co-Pay: This is a fixed amount that you pay for services rendered that is separate from the deductible. For example, there may be a fixed copay of $20 for a PCP visit.
      • Co-Insurance: This is worked into some health care plans where you pay a percent of each bill before the deductible is reached. For example, you may be required to pay 20% of each bill until you spend up to you $1,000 deductible.
      • Premium: This is the initial cost for the insurance plan, typically paid each month to maintain your coverage.
      • Network: A group of health care providers under contract with an insurance company. This is typically because the provider meets the insurers quality standards and/or because they have a pricing agreement.
      • Effective date: Day when the insurance coverage begins
      • Group health: A type of insurance that involves covering group members and their dependants, typically involving employees and employers
      • Limited Policies: Insurance for a narrow range of illnesses, such as cancer
      • Medicaid: This is a government sponsored insurance plan with income based eligibility, typically 200% below the poverty line.
      • Medicare: This is a government sponsored insurance plan with age based eligibility, typically 65 and older.
      • If there are more terms that are unclear, please refer to the link below. It contains nearly all of the keywords and terms or insurance in non-business terms.
      • Source:
  • The health care exchange/marketplace

The health exchange/marketplace is a provision of Patient Protection and Affordable Care Act. The implementation of the marketplace happened along with the banning of lifetime limits and denial of coverage based on pre-existing conditions. The exchange provides a group of federally approved health care plans for consumers to choose from. The marketplaces are not themselves responsible for risk involved with the insurance plans, but they choose plans that meet their quality standards. These exchanges can be either at the federal or state level, depending on where you live.


  • Federal vs state


        • The majority of people can register for the exchange through the federal marketplace. However, some states have opted out of the national marketplace and have created their own instead. There are currently 15 states that have a separate exchange, including New York, California, and the District of Columbia. For residents of these states, it is important to research the different rules and procedures for joining your state’s health exchange. Follow the link below for more information, and to see if your state has its own insurance marketplace.


  • How to sign up for the national exchange


Other Insurance Programs


  • Medicaid


          • This is a government funded insurance program that you can apply for during open enrollment period. The eligibility and requirements differs between states, but a good rule of thumb is that it covers children (through CHIP) and adults that are below the poverty level. Please review this chart to check if you are eligible in your state and for more information on how to enroll.
        • Medicare
          • Enrollment for this plan is typically automatic once you turn 65 years old. You should expect to receive your insurance card in the mail 2-3 months before your 65th birthday.
        • Supplemental Programs
          • If your program doesn’t cover all of your needs, there are types of insurance you can buy to supplement your primary plan. This could involve a supplement that helps paying for medications.




Coverage Legally/All Most Not/variable Explanation
Contraception/Family Planning X Under the PPACA, your insurance plan is required to cover contraception and family planning, unless you have a religious based employer.

However, this does not include abortions or male reproductive services. (Source)

Breast Health X Breast cancer screening: mammography only includes women over 40 years Under the PPACA, your insurance plan is required to cover preventative services including repeated screening, breast cancer chemoprevention counseling, and genetic test counseling for those at higher risk (
Pregnancy X If you have a baby, you become qualified for Special Enrollment Period, which allows you to enroll in or change Marketplace coverage. Under the PPACA, your Marketplace insurance plan and Medicaid covers pregnancy and childbirth. This coverage counts even if you were pregnant before your coverage started. Breastfeeding benefits are also included in this coverage. (
Menopause Well woman visits are offered as preventative services for women under 65 List of preventative care benefits for women
Mental Health X Under the PPACA, behavioral, mental health, and substance abuse care must be covered. It also provides parity protection, meaning insurance companies can’t impose restrictive financial, treatment, or care  management barriers. (Source)
Bone density Osteoporosis screening is offered to women over age 60 depending on risk factors
STDs Syphilis,  chlamydia, gonorrhea, HIV screening, and counseling for all the above are included HPV DNA test every 3 years for women at least 30 years of age with normal cytology results Under the PPACA, certain tests are covered under the Marketplace insurance
UTIs X Under the PPACA, you insurance plan is required to cover UTI screening if you are pregnant or may become pregnant.