What is health insurance?
Health insurance helps pay for covered medical expenses in exchange for a monthly premium, based on your plan’s benefits and rules.

What is a premium?
Your monthly payment to keep your plan active.

What is a deductible?
What you pay for covered services before your plan begins paying (depending on the benefit).

What is a copay?
A fixed amount you pay for certain services (like a doctor visit), if your plan uses copays.

What is coinsurance?
A percentage you may pay after meeting your deductible for certain services.

What is an out-of-pocket maximum?
A yearly cap on what you pay for covered in-network services under most major medical plans (rules vary by plan type).

What is the difference between HMO, PPO, and EPO?

• HMO: Typically requires in-network care and may require referrals

• PPO: Usually offers more flexibility and may include out-of-network options (higher cost)

• EPO: In-network only, usually no referrals, but no out-of-network coverage except emergencies

When can I enroll?
Usually during Open Enrollment or a Special Enrollment Period (if you have a qualifying life event). Some private options may be available year-round, depending on plan type and rules.

What is a qualifying life event?
Examples: losing job-based coverage, moving, marriage/divorce, having a baby, or other eligibility changes.

What if I miss Open Enrollment?
You may need to wait unless you qualify for a Special Enrollment Period or another coverage path.

What is an Explanation of Benefits (EOB)?
An EOB is a summary from your insurance company showing what services were billed, what the plan paid, and what you may owe.

How do I file a health insurance claim?
Most providers file claims for you. If you need to file manually, you’ll submit a claim form with receipts to your insurer.

Why are claims denied?
Common reasons include out-of-network services, missing prior authorization, coding issues, or plan limitations. Many denials can be appealed or clarified.

What is Medicaid, and who qualifies?
Medicaid is a state and federally funded program offering health coverage to low-income individuals. Eligibility varies by state and income level.

What is Medicare?
Medicare is a federal program providing health coverage for people aged 65 and older or those with certain disabilities.

Can I have both Medicaid and Medicare?
Yes, if you qualify for both, you may be “dual eligible” and get help with premiums, deductibles, and copays.

Does health insurance cover mental health services?
Yes. Under the Mental Health Parity Act and ACA, most plans must provide comparable coverage for mental health and substance use treatment.

Are prescription drugs covered?
Yes, but coverage varies by plan. Check the plan’s formulary (drug list) to see which medications are included and at what cost.

What happens if I move to a different state?
Moving can trigger a Special Enrollment Period. You’ll likely need to choose a new plan based on the new location.

Can I cancel my health insurance at any time?
You can usually cancel an individual plan anytime, but employer-sponsored plans may have specific rules. You may also lose COBRA or marketplace eligibility if you cancel voluntarily.

What is COBRA coverage?
COBRA allows you to keep your employer-sponsored insurance after losing your job or coverage (usually for up to 18–36 months), but you pay the full premium.

How do I appeal a denied claim or coverage decision?
You can file an internal appeal with your insurer, and if denied again, request an external review through a third party.