Health, life and income · Employer, Marketplace, Medicare, Medicaid
Health insurance
Pays for doctor visits, hospital care and prescriptions. Most Americans get it through a job, the government (Medicare or Medicaid), or a plan they buy on the marketplace.
- Who it's for
- Everyone. A single hospital stay in the US can cost tens of thousands of dollars.
- Is it required?
- No federal requirement since 2019, but California, Massachusetts, New Jersey, Rhode Island and Washington, D.C. require coverage and may charge a tax penalty. Some visas require specific coverage.
Covered and not covered
Usually covered
- Emergency care and hospital stays
- Doctor visits and specialists, often with a copay
- Prescription drugs, depending on the plan's drug list
- Preventive care, like checkups, vaccines and screenings, free in-network under ACA plans
- Pregnancy and childbirth, mental health, lab tests, and children's dental and vision. These are required in individual and small-group plans; most large employer plans cover them too.
- Pre-existing conditions: ACA plans can't exclude them or charge you more for them
Usually not covered
- Adult dental and vision care, which are usually separate plans
- Care outside the plan's network, for HMO and EPO plans, except emergencies
- Treatments needing prior authorization if you didn't get it
- Cosmetic procedures
- Long-term care, like a nursing home stay
- Most care outside the US
Real-life examples
You have a $10,000 surgery. Your plan has a $2,000 deductible, 20% coinsurance and a $6,000 out-of-pocket maximum.
Usually coveredYou pay the first $2,000 (your deductible), then 20% of the remaining $8,000, which is $1,600. Your total is $3,600; the plan pays $6,400. Once you've paid $6,000 in the year, the plan pays 100% until the year ends.
You go to the emergency room at an out-of-network hospital.
Usually coveredPlans must cover emergency care at in-network prices, and federal law (the No Surprises Act) protects you from most surprise out-of-network bills for emergencies.
You see a specialist without a referral on an HMO plan.
Usually not coveredHMO plans usually require your primary care doctor to refer you first. Without the referral, you may pay the full bill.
You get a filling at the dentist.
Usually not coveredAdult dental care isn't part of most medical plans. A separate dental plan usually covers cleanings fully and fillings partly.
What you pay, in order
Health plans share costs with you in stages. Knowing these four numbers tells you most of what a plan will cost.
1PremiumWhat you pay every month
You pay it whether or not you see a doctor. Employers usually pay part of it and take your share from your paycheck.
2DeductibleWhat you pay before the plan pays
For most services you pay the full price, at the plan's negotiated rate, until you reach the deductible. Preventive care and many copay services are exempt.
3Copay and coinsuranceYour share after that
A copay is a flat amount, like $30 a visit. Coinsurance is a percentage, like 20% of the bill.
4Out-of-pocket maximumThe most you pay in a year
After you reach it, the plan pays 100% of covered in-network care for the rest of the year. Premiums don't count toward it.
Where coverage comes from
| Source | Who it's for | Good to know |
|---|---|---|
| Employer plan | Employees and their families | The most common source. The employer usually pays a large share. Coverage typically ends when the job does. |
| Marketplace (HealthCare.gov or your state's site) | People without an affordable job-based plan | Help with premiums depends on income and immigration status. Sign up in open enrollment or after a life event. |
| Medicaid / CHIP | People with low incomes, and children | Run by each state, with different rules. A 2025 federal law narrowed eligibility for many non-citizens from October 2026; most green-card holders must wait 5 years. Emergency care is still covered. |
| Medicare | People 65+ and some with disabilities | Federal. Premium-free hospital coverage (Part A) usually needs 10 years of US work history, yours or a spouse's. |
| COBRA | People who just left a job | Keeps the same plan, usually for up to 18 months, but you pay the full cost plus up to 2%. Applies to employers with 20 or more employees; many states have similar rules for smaller ones. |
| Short-term plans | Temporary gaps | Not ACA plans: they can refuse pre-existing conditions and cap benefits. |
Health coverage rules, especially eligibility for help with premiums, change often. Check HealthCare.gov for the current year.
Plan types
| Type | Out-of-network care | Referral to see a specialist |
|---|---|---|
| HMO | Not covered, except emergencies | Usually required |
| EPO | Not covered, except emergencies | Usually not required |
| PPO | Partly covered, at a higher cost | Not required |
| POS | Partly covered | Usually required |
| HDHP | Depends on the network type | Depends. Can be paired with an HSA. |
Good to know
Reading your bills
After a visit, your plan sends an explanation of benefits. It is not a bill. Compare it with the provider's bill before paying: the amount you owe should match.
Dental and vision
Dental plans usually cover cleanings in full, fillings at 70 to 80%, and major work like crowns at about 50%, with a low yearly maximum, often $1,000 to $2,000. Vision plans cover an eye exam and part of glasses or contacts.
Check your own policy
Find these on your policy or declarations page, or ask your agent:
- Your premium, deductible and out-of-pocket maximum
- Plan type (HMO, PPO, EPO) and whether your doctors are in network
- Whether your regular prescriptions are on the drug list
- When coverage ends if you leave your job
Not sure where to look? See how to read your policy.