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  • Writer's pictureAhsan Malyk

How Health Insurance Works For Dummies?

Simply put, health insurance is a means of financing your medical care. When you are ill or wounded, your health insurance prevents you from having to pay the full cost of medical treatments.

It functions similarly to your house or auto insurance: either you or your employer choose a plan and agree to pay a predetermined rate, or premium, each month. Your health insurance consents to cover a portion of your covered medical expenses in exchange.

You join a community of others who have made the same decision by joining a health insurance plan. A risk pool is what we refer to here. Health insurers use this phrase to describe how much risk is shared by members of the same group.

What is a risk pool?

A risk pool is a collection of individuals whose medical expenses are pooled to determine premiums. Healthier people typically spend less, offsetting those who require more medical care and pay more. In general, premiums may be less expensive and more predictable the broader the risk pool.

When you require medical services

The main purpose of having health insurance is so you can avoid paying the full cost of medical services on your own. Some years you may require a lot of medical services, while other years you may need less.

When you require medical attention, you and your health insurer split the associated costs. Your health insurer may need to periodically change the rates for people who are insured if medical expenditures for the risk pool are unusually high.

Your plan specifies the out-of-pocket expenses you will incur for each service, including any copays, deductibles, and coinsurance.

How Medical Insurance Payments Are Made

Your monthly premium, or the amount you pay for health insurance, pays for some or all of the medical care you receive, including everything from prescription medications and doctor visits to customer service and health improvement programmes.

The majority of customers base their decision on a health insurance plan's monthly cost as well as its perks and medical services. However, there are more elements to take into account, such as the cost of visiting a doctor or medical institution.

These out-of-pocket expenses can be divided into several categories, and it's crucial to understand how they differ:


A deductible, which is the sum you must pay each year before your health insurance plan begins to pay for covered services, is a common feature of health insurance policies. If your plan, for instance, has a $1,000 deductible, you will be responsible for covering the first $1,000 of the costs associated with the medical care you receive.

Depending on the health plan, your insurance will start to cover some or all of your medical expenses once you have paid this sum.


A copay is a set amount you must pay each time you visit a doctor or use another covered service, such as an ER visit. You can be required to pay $20 to see your doctor, but $200 if you visit.


Co-insurance is a portion of the cost for some services that are covered, such as a visit to a specialist or a particular test. Your health insurance provider will cover 80% of the cost of the covered services if your co-insurance is 20%, and you will be responsible for the remaining 20%.

Out-of-pocket maximum

An out-of-pocket maximum is the most you will be required to pay for your medical costs for covered services you receive from doctors and hospitals that participate in the plan's network during a plan year (often a year). No matter what, you won't pay more than this sum for covered services during each plan month.

After you reach your out-of-pocket maximum, any care you get for covered services will be covered.

Health Insurance Plan Types

Medical insurance provided by one's own or a family member's employer is widely known. There are further sorts of health insurance, such as government-sponsored public health insurance.

Based on employment, health insurance that is offered by an employer to its employees as a benefit is known as employer-based insurance. The employer acquires insurance on the workers' behalf and may pay the entire or a portion of the plan premium. Employees may be required to pay a portion of the monthly premium, copays, coinsurance, or deductibles.


Those who meet the requirements can enrol in Medicare, a federal health insurance programme, regardless of their income. The beneficiaries of this plan must be 65 years of age or older or have a disability if they are younger.

Medicare is a four-part programme that the federal government oversees. Private insurance companies collaborate with the federal government to offer a wide range of coverage options and perks. Federal restrictions define eligibility.


The most needy citizens of our country, regardless of their backgrounds or location, can receive health insurance coverage through Medicaid, a joint state-federal safety-net programme, if they meet certain income and other qualifying conditions. As of March 2018, Medicaid provided health insurance to roughly 74 million Americans, including children, pregnant women, the elderly, people with disabilities, and people who are employed.

Personalized health insurance

Individual health insurance is medical coverage that is obtained privately rather than via a job or the government. Through the individual Marketplaces created by the Affordable Care Act, brokers or navigators, or directly from insurance providers, people can obtain coverage for themselves or their families.

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