Medical insurance is a type of health plan that helps cover the cost of healthcare services for individuals and their families. The insurance may be purchased through an employer or directly from the insurance company. It is regulated by state and federal laws.
The No Surprises Act protects consumers from unexpected and unforeseen costs associated with hospitalization and surgery (see below). Many insurance companies require preapproval for most services and may refuse to pay if you obtain these services outside the network of providers.
Deductibles and copays are upfront costs you have to pay before your insurance covers medical care. They’re usually listed in your ID card, along with your plan’s out-of-pocket maximum and a list of covered benefits.
Out-of-pocket maximum: The out-of-pocket maximum is the total of your deductible, copays and coinsurance (but does not include your premiums). If you use the entire amount of your out-of-pocket limit in one year, the insurance company will pick up all of your health care costs for that plan year.
Annual deductible: The deductible is the amount you pay each year before your insurance starts to pay for the medical services you receive. This amount is usually listed in your insurance ID card.
Coinsurance: If your doctor visits cost you $200, you would pay 20 percent of that amount. The insurance company would pay 80 percent of that cost, so you’d only have to pay $30 for the visit.
Most plans also have a set of preventive services that are typically covered at no extra cost. These include things like an annual checkup, a flu shot for your child and certain wellness screenings.
Getting Covered is the key to understanding how your insurance works and what you should expect when you receive care from a provider. It is important to understand your insurance plan’s deductibles, copays and other out-of-pocket expenses so you can make informed decisions about the best health care for you and your family.
What You Need to Know About Preventive Care
Increasingly, people are taking advantage of insurance coverage for preventive care and screening services. These services are important for overall health, reducing the risk of serious illness and death and can prevent costly treatment for conditions that are treatable.
Uninsured adults, in contrast, get less preventive and screen- ing care than their insured counterparts and receive it later. They are also more likely to receive care that is inappropriate for their condition (i.e., not recommended by their physician) or that is not based on evidence-based criteria for determining when a particular treatment is necessary.
While these findings are promising, more research is needed to determine whether and how health insurance affects care and outcomes. In addition, it is important to note that most studies are observational in nature, including only those who “show up” for care (i.e., attend medical appointments or receive diagnostic tests). Moreover, most studies do not have appropriateness criteria for determining when certain treatments are considered necessary. For example, in the case of heart disease, patients who have insurance are much more likely to receive treatment after an acute coronary artery attack (AMI) than those who do not.