We’ve Got You Covered: The Basics of Health Insurance
Choosing a health insurance plan can be a confusing and frustrating task—so we break down the basics to help you choose an insurance plan that meets your particular needs.
Health Insurance 101
Knowledge is power—and you’ll get better care if you know the basics about choosing a health plan. These questions will help you get started:
Where do I look to find a health insurance plan? Try visiting Healthcare.gov. The site has information on plans, costs, and just about anything you want to know about health insurance. You can also apply for a health plan online, or you can call (800) 318-2596 to get personal help with your application.
What are the most important factors in choosing a health plan? That’s easy—how much it really costs (more on that below) and what services it covers. The challenge is to make sure the plan you choose covers your specific health needs—and that may require some detective work on your end.
What kind of coverage do I need? Federal law requires all health plans to offer a basic set of services, but it’s important to remember that no two plans are alike. It’s on you to be sure a plan meets your needs. Your health and your financial stability could be at risk if you don’t.
For example, some HIV drugs can cost thousands of dollars every month if they aren’t covered by insurance. So if you’re living with HIV, or taking PrEP to protect yourself from getting it, be sure to check the plan’s prescription drug benefits and find out whether it will pay for the meds you need. And if you’re transgender, look out for language in a plan that specifically excludes services you need or want.
How much will it cost? That depends. Every plan splits some costs between you and the insurance company—that split determines the price of your plan. To figure out how much you’ll have to spend, you have to look at several different kinds of costs, including “premiums,” “deductibles,” “co-pays,” “co-insurance,” and “out-of-pocket maximums.”
What do those terms mean? They refer to the things YOU have to pay for when you buy a health plan:
- Premiums are the payments you send to the insurance company every month.
- All health plans have a deductible, which is a set amount you have to pay for your care before the insurance company will start picking up the tab. For example, if your deductible is $1,000, your plan may not pay for anything until you’ve shelled out the full $1,000 for covered services.
- Co-pays are a fixed amount (e.g., $10) you pay each time you visit a healthcare provider, get a prescription, or have a medical procedure. They usually don’t count toward your deductible, but be sure to ask.
- Even after you meet your deductible, you’re still on the hook for co-insurance, which is a percentage (e.g., 20%) of the amount your provider can charge for a service. For example, if your provider charges $100 for an office visit and you’ve met your deductible, your 20% co-insurance payment would be $20. The insurance company pays the rest.
- Finally, there’s the out-of-pocket maximum. That’s the most you have to spend for covered services in a year. Once you’ve hit that limit, your plan pays 100% for covered services.
Which one of those costs is likely to hit my wallet the hardest? That depends on how much you use your insurance and the services you are most likely to need. Things to consider:
- Your deductible has a big impact on the “sticker price:” Large Deductibles=Lower Premiums.
- But that’s not the whole story. You have to look at the trade-off between paying more every month or having to be prepared for larger bills if you get sick or hurt.
- You also have to consider how much you will spend for co-pays and co-insurance. You can lay out a lot of cash if you visit the doctor often, or take a lot of prescription drugs. A plan with a higher monthly premium but lower co-pays could save you serious money.
- Some plans pay for things like doctors’ visits and prescriptions before you meet your deductible. That’s a big benefit, so check to see if your plan is one of them before you sign up for coverage.
FYI: No matter what plan you choose, you are legally entitled to a number of preventive services—like screening tests for HIV and vaccinations—without having to pay any deductibles or co-pays.
Can I get help to pay for a plan? Depending on your income, and where you live, you may be able to get a break on the cost of your plan. Use the Healthcare.gov tool to see if you qualify for financial help.
How do I find a healthcare provider? You’ll need to look for providers who accept your insurance plan. You can ask your insurance company for a list, and most companies have online directories to give you information about your choice of providers. You can also check out our Provider Directory! It connects Black men who have sex with men to accurate, safe, respectful, and comprehensive care.