Medical insurance is a form of health care that helps pay for many preventive services, hospital stays, surgeries and other medical needs. It also covers medications and prescriptions. There are a variety of types of medical insurance plans, including fee-for-service, managed care and Medicare Advantage. Many people have group health insurance through their employer, but individuals can buy individual policies or qualify for a public program to help cover costs (see pages 14 and 16). Whether you have group or individual coverage, there are some important terms you should know, such as deductibles, copayments and coinsurance.

Deductibles are fixed amounts you must pay before the insurance company begins to pay for covered services. You also may have a yearly limit on how much you must spend on coinsurance, which is a percentage of the cost of a service after you reach a certain amount. Most health plans have a network of doctors, hospitals and other providers from which you can choose. Generally, you will pay less if you use providers that are part of your plan’s network—called preferred providers.

Most managed care plans—including HMOs and point-of-service plans—require you to choose a primary care doctor who oversees your care and makes referrals for specialists. Preferred provider organizations, on the other hand, usually don’t require referrals and offer a wider choice of doctors.

Out-of-network provider

An out-of-network provider is one who doesn’t have a contract with your insurance company to provide care at negotiated rates. You typically will pay more to see out-of-network providers, even after you meet your deductible.

Tiered network

A medical provider network that offers several cost levels, with lower-level networks offering a higher degree of coverage and higher-level networks offering a lower level of coverage. You typically pay more to see providers in the highest tier.

Pre-existing condition

A health condition you had before you joined a group plan or purchased individual coverage, or before your policy became effective. Some plans have restrictions on coverage for those with pre-existing conditions, but others do not.

If you have a problem with your health insurance, first try to resolve it with your doctor or the insurer. If you can’t come to an agreement, you can file a complaint with your state’s department of insurance. The department will investigate your complaint and make a decision. If you have an urgent need, the department may do an Expedited Review, which requires the insurance company to review your case as soon as possible. This may allow you to continue getting treatment until a final decision is made. If you have a problem with the way your case was handled, you can ask for a fair hearing or appeal. See page 17 for more information. The Affordable Care Act (ACA) has brought about a number of changes to how medical insurance works. For example, most plans now must provide a full set of essential benefits, offer a choice of doctors and hospitals, and not deny you coverage because of a pre-existing condition.