Prestige Professional Management
Your Consumer Resource Specialist
HomeWhy do you need health insurance?
Health insurance helps pay the costs for medical care that you or covered dependents receive. Without it, you may pay the full cost for all your care. Most health plans provide you with a network of participating doctors, specialists, other health care practitioners, and facilities to choose from. These network doctors, hospitals, and others offer lower rates than those outside the health plan’s network, which helps keep your costs lower. Having a health plan encourages you to see your doctor for your annual check-up and other preventive care. This helps identify any health issues early before they become serious. And most health plans provide 100% coverage for certain in-network preventive care.
Why have health insurance if you’re young and healthy?
One of the main reasons why health insurance is important is that you want to stay healthy, right? One of the best ways to help you do that is to make sure you see your doctor for your annual check-up, get your flu shot, and other preventive care. It’s covered 100% by most health insurance plans when you stay in-network. Without health insurance, you may have to pay the full cost of any medical care you receive, including preventive care.
Health insurance is important for other reasons, as well: if you do get sick or suddenly need emergency care, health insurance plans help cover some of those costs. Otherwise you may be on your own paying the high cost for care. Is there health insurance for healthy people?
Yes. If you are healthy, you may want to consider health plans with higher deductibles and lower monthly premiums. Plans like these will help you save money if you don’t expect to have a lot of medical expenses during the plan year.
If you enroll in a Qualified High Deductible Health Plan, you may also be eligible to open a Health Savings Account (HSA) which can help you save money on taxes and pay for eligible health care expenses.
What happens if you don’t have health insurance?
There are a couple of things that can happen if you don’t have health insurance: you may be more likely to avoid getting recommended preventive care. You may be responsible for paying the full cost of any medical care if you happen to get sick, injured, or develop a chronic illness. If you don’t obtain "Minimum Essential Coverage" as defined under the Affordable Care Act (ACA), you may need to pay a tax penalty. The main reason why health insurance is important is it helps you get the care you need—even if it’s basic preventive care—at a price you can afford.
How Does Health Insurance Work?
Health insurance works to help lower the amount you would otherwise have to pay for high-cost medical care. This is typically how a health plan works, but they can vary:
You pay a premium—usually monthly. This is a fee for having the health plan. Most health plans have a deductible. A deductible is how much you must pay out of pocket for care until your health plan kicks in to share a percentage of the costs. Once you meet your deductible and your plan kicks in, you start sharing costs with your plan. For example, your health plan may pay 80% of your medical costs and you may pay 20%. This is called “coinsurance.” Most insurance ID cards show your deductible and coinsurance.
Preventive care is typically covered 100%. This includes things like your annual check-up, a flu shot, vaccinations for kids, certain wellness screenings, and more. Some plans may require a copay—a small fee you pay at the time of the doctor visit. You save money when you stay in-network. Network providers agree to give lower rates to the insurance company’s customers. You can usually find a list of network providers on your health insurance website, or by calling and asking them for a list of in-network providers. This is a key part of how health insurance works to help keep your costs low. Your health insurance may also come with extra no-cost programs and services. This may include health and wellness discounts for services and products, incentive programs where you can earn cash awards and other prizes for completing healthy activities, and more.
What does health insurance cover?
Health insurance plans may cover a wide range of medical care and services. These often include preventive and non-preventive care, as well as emergency care, behavioral health, and sometimes vision and hearing.
What you pay out-of-pocket and what your plan helps pay for can depend on a number of factors. These factors include whether you’ve met your deductible, what your coinsurance is, if you are getting care from in-network providers and facilities, if your care is preventive or not, and more.
Here are examples of health insurance benefits your plan may cover:
Preventive visits: Things like an annual check-up (adult or child) are typically covered 100%.
Vaccinations: Some vaccinations are covered 100%, too. For example, many plans pay for an annual flu shot and certain kinds of childhood vaccinations.
Non-preventive doctor visits: For in-network doctors and specialists, you get a reduced rate as part of the network. Your plan helps pay its share of the cost once you’ve met your deductible.
Hospitalization: Your plan helps pay its share of the cost once you’ve met your deductible. You will pay less if you go to a hospital that’s in your plan’s network, if required.
Emergency Room: Many health plans do not require you to go to an in-network ER in an emergency, but plans can differ.
Lab work: If you go to an in-network lab, your costs for lab work will be lower. Your health plan negotiates lower rates with them, too.
Additional, or supplemental coverage that’s added to your health plan: Coverage for cancer care, accident coverage, and more can help you pay for care that’s often costly and unexpected.
What does health insurance not cover?
What’s not covered by health insurance can also vary depending on the plan.
Here are some types of services that are not typically covered:
Alternative medicine: Such as massage, acupuncture, herbal healing, and more.
Cosmetic surgery: Things like plastic surgery, laser skin removal, liposuction, rhinoplasty (nose job), etc.
Weight-loss surgery: Gastric bypass and bariatric surgery may not be covered. This depends on the plan you get, though. Some procedures may be covered if medically necessary, so check your plan documents carefully.
Vein surgery: Laser surgery to correct spider veins is often considered cosmetic and may not be covered unless a doctor can show it’s medically necessary.
Elective surgeries: Especially surgeries that a doctor cannot prove a medical need for.
Unapproved medical care: If you fail to get a required prior authorization for care or a service, your health plan may deny you coverage. Prior authorization is pre-approval from your health insurer. Many health plans require this type of pre-approval for certain types of procedures or treatments.
Experimental treatments or procedures: For example, surgeries that use new technology or methods that may not have proven outcomes.
Your Summary of Benefits Coverage (SBC) document that comes with your health plan will itemize the care and services covered, as well as what’s not covered. When you know how your health plan works, you are better able to avoid paying unnecessary out-of-pocket costs.
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