FAQs
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General Health Insurance FAQs
General Health Insurance FAQs
What is health insurance?
Health insurance is a contract that requires an insurer to cover some or all of your medical expenses in exchange for a monthly premium.
What does health insurance typically cover?
Most plans cover doctor visits, hospital stays, preventive care, prescription drugs, and emergency services. Coverage specifics vary by plan.
What is a premium?
A premium is the amount you pay for your health insurance every month.
What is a deductible?
A deductible is the amount you pay out-of-pocket for healthcare services before your insurance starts to pay.
What is a copay?
A copay is a fixed amount you pay for a covered healthcare service (e.g., $25 for a doctor's visit).
What is coinsurance?
Coinsurance is the percentage of costs you pay for a covered service after you've met your deductible (e.g., 20%).
What’s the difference between HMO, PPO, and EPO plans?
HMO: Requires referrals and in-network providers only.
PPO: More flexibility to see out-of-network providers, no referrals needed.
EPO: No referrals needed, but limited to in-network providers.
Enrollment and Eligibility
Enrollment and Eligibility
When can I enroll in health insurance?
You can enroll during Open Enrollment or during a Special Enrollment Period if you experience a qualifying life event (e.g., marriage, birth, job loss).
What is a qualifying life event?
Events like marriage, divorce, childbirth, loss of coverage, or moving to a new state can allow for Special Enrollment.
Can I stay on my parents’ health insurance?
Yes, until you turn 26 under the Affordable Care Act (ACA).
What if I miss Open Enrollment?
You may need to wait until the next period unless you qualify for Special Enrollment or Medicaid.
Family and Dependent Coverage
Family and Dependent Coverage
Can I add my spouse or children to my health insurance plan?
Yes, most plans allow you to add a spouse and dependents during open enrollment or after a qualifying life event.
How do I remove a dependent from my plan?
You can remove a dependent during open enrollment or if you have a qualifying life event, such as divorce or a child aging out.
Does my newborn automatically get covered?
Most plans will cover a newborn for the first 30 days, but you must formally add them to your policy within that period to continue coverage.
Costs and Savings
Costs and Savings
What is an out-of-pocket maximum?
The most you’ll pay in a year for covered services. After reaching it, your insurance covers 100% of costs.
Are preventive services covered?
Yes, most plans cover preventive services (e.g., screenings, vaccines) at no additional cost when provided by in-network doctors.
Can I use a Health Savings Account (HSA)?
You can if you have a High Deductible Health Plan (HDHP). HSAs allow you to save pre-tax money for qualified medical expenses.
How can I lower my health insurance costs?
Consider subsidies via the Marketplace, shop around for plans, or use HSAs/FSAs for tax savings.
What happens if I don’t have health insurance?
While there's no federal penalty as of 2019, some states may have mandates. You’ll also risk high out-of-pocket costs if you need care.
Claims and Billing
Claims and Billing
What is an Explanation of Benefits (EOB)?
An EOB is a summary from your insurance company showing what services were billed, what they covered, 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 was my claim denied?
Common reasons include out-of-network services, lack of pre-authorization, or incomplete documentation. You can appeal the decision.
What does "in-network" mean?
In-network providers have contracts with your insurer to offer services at negotiated rates. Using them usually saves you money.
Medicaid and Medicare
Medicaid and Medicare
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.
Special Scenarios and Coverage Questions
Special Scenarios and Coverage Questions
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.
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