What is health insurance and how does it work? 

5 mins readLast updated October 4, 2023by Kate Morgan

Health insurance is a type of insurance coverage that pays for medical and surgical costs incurred by the insured person. Learn more about health insurance here.

America’s healthcare landscape is complex, offering a combination of federal, state, and private options.

How does health insurance work for people in the US? Read on and find out.

From Medicaid and CHIP to HMOs and EPOs, here’s everything you need to know to find the right healthcare plan.

What is health insurance?

Health insurance is a type of coverage taken out by an individual or a family to cover healthcare bills for everything from the birth of a child to a broken arm.

When the average cost of a single doctor’s visit in the US is $200 to $300, it’s easy to see why health insurance is so essential.  

Health insurance exists as a contract between a person (or multiple persons) and a company.

Usually, a monthly premium is paid, and in return, the insurance company agrees to pay some or all of the medical and surgical costs that the health insurance policyholder incurs when they happen to need them.  

Many different types and coverage levels are available depending on preferences and circumstances.

For example, healthcare is often offered to employees by employers as part of a benefits package, options like Medicaid and Medicare are available to help support retirees or those with lower incomes, and there are private insurance organizations for those who can afford them.

What types of health insurance are available?

There are four types of health insurance available to US citizens – private medical insurance, Medicare, Medicaid, and CHIP (the Children’s Health Insurance Program).

Your eligibility for any of these insurance types depends on various factors. 

1. Private medical insurance 

There are a few private medical insurance options available through about a thousand providers in the US.

Plans and prices are configured based on an individual’s medical history, but the five main options are:  

  • HMOs (Health Maintenance Organizations) – These providers, of which there is a limited number, offer low co-payments and cover costs for preventative care.  

  • PPOs (Preferred Provider Organizations) – These providers offer more care provision flexibility and give you more plan choices, like the Multiplan PHCS Network. 

  • HDHPs (High-Deductible Health Plans) – These plans come with higher deductibles and lower premiums and allow a Health Savings Account (HSA).  

  • POSs (Point-of-Service Plans) – Under these plans, you pay less for doctors, hospitals, and other care services if they’re within the plan’s network. 

  • EPOs (Exclusive Provider Organization Plans) – These plans cover doctors, hospitals, or specialists in the network unless it’s an emergency. 

2. Medicare  

Medicare mainly covers healthcare costs for retirees or people over 65, but younger people with conditions like renal disease or ALS are also eligible.

It comprises four parts – A, B, C, and D.  

Part A covers hospital, skilled nursing, and hospice services.

Part B covers outpatient services, some providers’ inpatient services, and hospital charges.

Part C covers health plans with some of the same services as Parts A and B, and access to out-of-pocket expenses not included in those.

Part D predominantly covers the costs of prescription drugs.  

3. Medicaid 

Medicaid is the American public health insurance program for families and individuals on low incomes.

Almost 83 million people are currently enrolled in Medicaid insurance options across 50 states.

It’s the most accessible option for poorer citizens and the most significant funding source for their medical needs. 

Medicaid is offered by a combination of state and federal organizations.

It can also be used alongside Medicare by less well-off older or disabled people to cover some benefits not included in Medicare, like nursing home services.  

4. Children’s Health Insurance Program (CHIP) 

Some American families have too high an income to be eligible for Medicaid but still don’t earn enough to afford private insurance.

As inflation increases, this gap between groups increases.

That’s where the Children’s Health Insurance Program (CHIP) comes in.  

Another option that relies on federal and state funding, CHIP gives children from families who aren’t eligible for Medicaid access to low-cost health coverage.

This coverage includes check-ups, immunizations, dental, prescriptions, emergency services, and more.

In some states, CHIP also covers care for pregnant women.  

How much does health insurance cost?

As of 2022, the average annual cost of health insurance in the US is $7,739 for an individual or $22,221 for a family.

If your employer is subsidizing your insurance, they usually cover about 75 per cent, so the rest of this figure still needs to be accounted for. 

Ultimately, how much you pay for health insurance can change a lot depending on your circumstances, finances, and choices.

Paying for private insurance equals paying much more, and factors like location, age, family size, and lifestyle can also affect the cost of your premium considerably. 

Do I need health insurance?

Most US citizens have wondered “Should I get health insurance?” The short answer is yes.

If you need medical services and don’t have coverage, you could end up unable to pay your bills and in a worst-case scenario, completely turned away and refused treatment by a provider.

This could lead to an ever-worsening situation in terms of your health and finances. 

By setting yourself up with a good policy, you ensure you’re prepared (and if you have a family, that they are) in the event of an emergency or other medical occurrence. And you ensure that if treatment costs start racking up, you’re not solely responsible for that mounting bill. 

How to get health insurance

Many in the US get health insurance through their employers. If you don’t, you need to purchase it.

Available options are listed on your state’s “marketplace,” which also breaks down the monthly premiums associated.

As of 2022, most states provide at least some Medicaid coverage for people on a low income.

You can also enroll in a health insurance scheme if this is viable in your situation. 

You need to figure out how to get health insurance if you're unemployed.

Thankfully, if you have savings, you should still be able to find a provider based on your income and household size.

Some unemployed people can also qualify for free or low-cost Medicaid or CHIP funding. 

As of 2022, getting health insurance without a job or a high income is a little easier.

In all, 39 states have now expanded their Medicaid options to cover all households with incomes under $17,774.  

More helpful information about health insurance and health insurance alternatives is available on our website.

Content writer

Kate Morgan

Kate has written for leading publications and blue chip companies over the last 20 years.