What to do if I can’t afford health insurance?

Health insurance is an agreement that assists in covering medical treatments, physician appointments, and hospital expenses in the US. Most people obtain health insurance through work, government assistance such as Medicaid or Medicare, or individually.

Every plan has different regulations, monthly premiums and what it covers. Knowing these basics can assist when selecting a plan or navigating benefits. The following sections distill the key facts about health insurance.

The main types of health insurance

There are two big categories of health insurance in the US, private and public. Private health insurance encompasses employer-sponsored and individual plans, whereas public options are such as Medicare and Medicaid.

Most private plans break down into main types: HMO, PPO, EPO, POS, and HDHP. Every one of these plans has its own guidelines about choosing physicians, consulting specialists, and covering fees. Plans are divided into metal levels—Bronze, Silver, Gold, and Platinum—which indicate the percentage of expenses you and the plan each cover.

Bronze covers approximately 60% of expenses, Silver 70%, Gold 80%, and Platinum 90%. Catastrophic plans are yet another with low monthly payments and high deductibles, primarily for emergencies.

1. HMO plans

HMO = Health Maintenance Organization. You select a primary care physician to coordinate your care and provide referrals when specialist treatment is necessary. Care has to be in network most of the time.

If you’re out-of-network, generally you pay 100%. HMO plans usually have lower monthly payments than other types. You sacrifice some freedom — out-of-network care is uncommon unless it’s an emergency.

If you like predictable costs and don’t mind working through one doctor, HMO may be a good fit. You pay copays for most visits and there’s an out-of-pocket max that caps your annual costs.

2. PPO plans

What does PPO mean? These plans provide you much more freedom in selecting physicians. You don’t need a referral to go see a specialist, which makes it easier if you want to bypass the primary doctor step.

PPOs cost more every month than HMOs, and you pay more out of pocket if you choose a network doctor. You still get some coverage for out-of-network care, which is convenient if you travel or desire a particular provider.

PPO plans are good for individuals who desire flexibility and don’t mind paying extra for it.

3. EPO plans

EPO stands for Exclusive Provider Organization. These plans only cover care in the plan’s network, except in emergencies. You don’t require a referral to visit a specialist.

For those who’re OK with adhering to a fixed doctor network, EPOs translate into lower monthly premiums than PPOs — but less flexibility. EPOs are a nice compromise—less expensive than PPOs, more flexibility than HMOs.

4. POS plans

POS plans combine features of HMOs and PPOs. You select a primary physician and require referrals to see specialists. You can see out-of-network providers, it just costs more.

POS is great if you want a primary physician directing your care but want the ability to go out of network. POS plans can be a wise choice for individuals who desire both organization and a bit of flexibility.

Costs fall somewhere between HMO and PPO plans.

5. HDHP plans

HDHPs have bigger deductibles and lower monthly costs. You can use an HSA with them, allowing you to save money tax-free on medical bills.

Preventive care is typically covered prior to reaching your deductible. HDHPs fit healthy folks who rarely visit a doctor but desire a safety net.

Where to get health insurance

Many of us access health care coverage through employment, the federal or state marketplaces, or government programs, including private health insurance companies, each with regulations on enrollment and fees.

Employer plans

Employer-sponsored health insurance is the most frequent source of coverage for Americans. These plans may often provide robust coverage for employees and their families, including reduced premiums and the option to select physicians.

Nearly all of these companies provide some sort of group health benefit plan, which diversifies risk and may translate to reduced premiums for all. Employers typically contribute toward the monthly premium, so coverage is less expensive than purchasing a plan independently.

Federal regulations, including the Affordable Care Act, mandate that big employers provide health coverage to their full-time employees. Workers can maintain coverage for dependents, and young adults can remain on a parent’s plan until age 26. If you lose your job or switch jobs, you can hang onto your coverage through COBRA, but you foot the full premium.

Marketplace plans

Health insurance marketplaces, established under the ACA, allow individuals to purchase individual or family plans if they’re not offered insurance through their employer. Premium tax credits and subsidies make health care coverage affordable for many, but you need to meet certain requirements about household income and size. The health benefits provided can vary significantly based on the selected plan.

The open enrollment period takes place every fall, and those who welcome a baby into the family, relocate, or lose other coverage could be eligible for special enrollment. Marketplace plans are divided into tiers—Bronze, Silver, Gold, and Platinum—which each strike a different balance between your monthly premium and out-of-pocket costs.

It’s in the marketplace that self-employed people, freelancers, and others without job-based coverage can shop for plans that meet their specific needs, ensuring they have access to essential health benefits.

Government plans

Public programs cover the gaps for populations such as seniors, low-income families and individuals with disabilities. Medicare for 65+ or health conditions Medicaid and CHIP assist low-income adults and children — each state establishes its own guidelines.

These plans encompass many essentials, including hospitalizations and physician appointments, and you can sign up at any time, not solely during open enrollment. Gaining entry to these programs requires satisfying rigid criteria, frequently relating to age, income or medical condition.

They’re a huge deal for folks who otherwise wouldn’t get covered.

Private plans

Private insurers offer plans outside of work or government. These are available as individual and family plans, and purchasers can go via brokers, direct to insurers, or in some cases through groups or associations.

Private plans might provide more options for coverage and benefits, so purchasers can select what suits their desires. Private plan costs can be higher, particularly if you want lots of coverage or have health needs.

Self-employed individuals and small business owners sometimes ‘band’ together for group or association plans.

Understand health insurance costs

Health insurance costs in the US are two different things and understanding what each one means helps you budget for care without going broke. Here are the key components:

• Premiums: monthly payments to keep health insurance active
• Deductibles: the amount you pay for care before insurance starts to pay
• Copays: fixed fees for certain services, like a doctor’s visit
• Coinsurance: the percentage of costs you pay after meeting your deductible
• Out-of-pocket maximums: the most you’ll spend in a year for covered services

Once you understand how these work, you’ll be able to better manage your healthcare spending, compare plans, and avoid surprises. The sweet spot between cost and coverage means you’re not overpaying for care you don’t need, or underinsured if something major happens. I think it’s clever to break it down, review what applies to you, and schedule your budget around actual costs.

Your premium

Your health insurance premium is what you pay each month regardless of whether you seek care. This premium keeps your coverage in force. Premiums can consume a huge portion of your monthly budget, particularly if you’re older or have a large family.

A 30-year-old, for instance, may pay $618 per month for a PPO plan, while a 60-year-old may pay $1,478. Certain states have higher premiums, and if you use tobacco, insurers can charge you up to 50% more (state-dependent).

Identifying premium differences across plans matters. Low premium plans tend to go hand-in-hand with high deductibles or copays – and the least expensive option every month isn’t necessarily a bargain if you require a lot of care. Picking the right premium level can help ensure that you don’t overpay for health insurance while still having access to care when you need it.

Your deductible

A deductible is what you pay out of pocket at the beginning of each year for covered medical services before your insurance company chips in. Until you reach that figure, you’re paying full price for the majority care.

There are plans with deductibles as low as a few hundred dollars, but others can be several thousands. If you choose a plan with a high deductible, your monthly premium could be less expensive, but you’ll pay more out-of-pocket if you require care. High-deductible plans are smarter for those who manage to avoid regular doctor or hospital care.

Getting to your deductible is an important base to before insurance begins cost-sharing. It’s especially crucial to understand your plan’s deductible, so you’re not blindsided by big bills in the first few months of the year.

Your copay

A copay is a fixed amount you pay up front for certain services. If your plan says you have a $30 copay for a primary care visit, you pay $30 at check-in, and insurance pays the rest.

Copays can be $25 to $40 for a doctor’s visit, but specialty care or ER visits are higher. Each plan sets different copays for primary care, specialists, urgent care or prescriptions. Understanding your copays prior to seeking care lets you budget and plan. Some plans waive copays for preventive care — read the fine print.

Your coinsurance

Coinsurance is your portion of costs once you meet your deductible. If your plan has 20% coinsurance, for example, you pay 20% of the bill, insurance pays 80%. This, unlike a copay, is not a flat fee.

These coinsurance rates may be higher or lower based on the plan and type of service. For instance, you could pay extra for out of network care. Coinsurance is a major component of your total expenditures if you require a lot of care or are confronted with a large medical bill.

When can you enroll

Health insurance enrollment periods determine when you can enroll, modify, or cancel your health care coverage. Missing these windows can mean waiting months for coverage unless you experience certain life events impacting your health plan.

Open enrollment

Open enrollment is the primary opportunity most people have annually to obtain or modify health care coverage. It typically occurs annually for a limited time, though the timing may vary. During this window, you can select a new plan, change plans, add family members, or drop coverage, ensuring you have access to the best health solutions available.

If you enroll through Open Enrollment in 2024, you’ll be covered in January or February of 2025. This time is crucial since it’s the only opportunity most of us have to shop around, compare plans and select what works best for our health and wallet.

Checking out your options can help you locate better prices or coverage — particularly if your health needs or income have shifted since last year. Most plans renew automatically, but prices, benefits and provider networks may change annually. Even if your plan renews, it’s good to see if another plan suits you better.

If you miss open enrollment you’ll have to wait until next year unless you qualify for special enrollment. Not enrolling could result in you going months uncovered, which leaves you shouldering high out-of-pocket costs in the event you need care.

Special enrollment

Special enrollment allows you to enroll in coverage outside of open enrollment, but only if you’ve experienced a triggering life event. These encompass losing other health coverage, getting hitched, having a baby, relocating to a new state, or a dip or rise in income/family size.

If you’re low-income, you may be able to enroll anytime. To obtain special enrollment, you are required to provide evidence of your life event—such as a marriage certificate, proof of changed address, or proof of lost coverage.

We’ll want this paperwork to establish that you qualify under the special enrollment rules. You typically have 60 days from the event to sign up. It’s good to know what constitutes a qualifying life event.

Life changes don’t wait and if you miss the 60-days, you may have to wait until the next open enrollment. Keeping track of these rules will help ensure you don’t lose health insurance when you need it most.

Special enrollment prevents your coverage from expiring. It’s particularly handy following significant life transitions. If you enroll soon after a triggering event, you can steer clear of coverage gaps and surprise expenses.

How modern plans are changing

Modern health insurance ain’t yer grandma’s health insurance anymore. Things are different today — plans mix technology, new care models, and greater options to suit people’s lives. Consumers want more voice in care. More than 80% seek customization. Corporations fight for customized plans.

Most individuals—92%—can choose between a minimum of three distinct insurance plans. Nearly a third are even thinking of switching, particularly among 26–45-year olds. Change is constant, but it raises new questions — particularly around pre-existing condition coverage and how emerging tech influences daily consumption.

Telemedicine access

Telemedicine is now a staple in many health plans, providing essential health benefits through virtual doctor, therapist, and specialist visits that have transitioned from niche to normal. These telehealth services allow individuals to access medical care without leaving home, which is particularly beneficial for those miles away from clinics or requiring after-hours care. The convenience of telemedicine improves the patient experience significantly.

Telemedicine frequently includes urgent care, mental health services, follow-ups, and even chronic care management. A few plans have rolled out ‘telehealth-first’ models, placing online visits at the core of care, which can reduce administrative burden and save money by avoiding unnecessary ER visits. This proactive approach enables physicians to intervene earlier, preventing small problems from escalating.

Most major insurers now cover telemedicine, with some plans reimbursing video visits at the same rate as in-person ones. For instance, Blue Cross Blue Shield, Cigna, and UnitedHealthcare feature telehealth prominently in their group and individual plans, reflecting a shift towards innovative health solutions in the insurance marketplace.

Wellness perks

Wellness perks are becoming more prevalent in modern health plans, including free gym memberships, flu shots, and health screenings. These health solutions aim to keep people healthy and reduce long-term costs for both patients and insurers. By incorporating wellness benefits, such as meal delivery for chronic illness, decision-making when selecting a term health insurance plan can be significantly influenced.

Throwing in wellness benefits can tip a decision when selecting a plan. Others connect premium discounts or cash rewards to healthy behaviors, such as walking a certain number of steps or quitting smoking. Employers value these perks as they help boost worker morale and reduce sick days, which aids productivity.

Wellness programs also provide essential resources for stress management, weight loss, and tobacco cessation, contributing to a better patient experience. These small additions accumulate to create a comprehensive approach to health care coverage.

Digital tools

Tech is transforming our health insurance habits. Secure mobile apps to track claims, schedule visits and check coverage–now table stakes. Approximately 64% of individuals are okay with using these applications. Services such as MyChart, Oscar and Aetna’s Health app help keep health information centralized and provide round-the-clock communication with care teams.

Digital tools mean less paperwork, fewer phone calls and faster answers. Patients can even receive reminders for screenings or refills. Technology facilitates cost comparisons or locating in-network providers. That assists them to make smarter decisions.

Digital care is included in the majority of plans. It’s a shift from reactive to proactive care, relying on reminders and online check-ins to keep people healthy to begin with.

New care models

Value-based care and telehealth-first plans are rewriting the playbook. These models are more outcome and prevention-focused, rather than visit count-based. They have to check if their plan pays for these choices, particularly if they’re pre-existing.

With new plans, keeping on top of coverage changes is important.

What about supplemental coverage

Supplemental coverage provides additional protection that fills the holes in a standard health insurance plan. It covers what normal policies don’t – specific treatments, hospital bills or everyday costs when you’re unwell or injured. A lot of people get these plans through employer or directly from insurers.

There’s a lot of types, including dental, vision, accident, hospital indemnity, critical illness, and cancer insurance. Some charge a flat fee, others a daily or event fee. Not everybody’s deal is the same—depending on your job, your health, or falling within open enrollment, you may be eligible for some types of coverage and not others.

Dental insurance

The most popular form of supplemental coverage is dental insurance. As we know, good oral health is connected with overall wellness, but the majority of traditional health insurance plans do not include coverage for basic dental care.

Dental insurance comes into the picture to assist with covering routine visits, fillings, crowns, and occasionally even some orthodontics. A standard dental plan includes checkups, cleanings, X-rays and emergency services. Certain plans dive deeper with coverage for larger procedures, such as root canals or oral surgery.

These advantages can make dental insurance a savvy way to control expenses. Without coverage, one crown or root canal can cost you hundreds or thousands of dollars. Dental insurance helps reduce these costs, either by splitting the bill or limiting your out-of-pocket expenses.

Over time though, routine dental coverage can help catch issues early, which translates into fewer major print expenses down the line.

Vision insurance

Most vision insurance plans cover eye exams, glasses, and contacts. Some even give discounts on corrective surgery. Regular eye exams do more than check your sight—they can spot signs of diabetes, high blood pressure, and other health issues.

Vision insurance makes it easier and cheaper to keep up with this care, which can be important for anyone who wears glasses or contacts. For families, especially those with kids who need new glasses often, this coverage can save a lot each year.

Service	Typical Coverage	Financial Advantage
Eye exams	Covered annually	Reduces out-of-pocket costs
Glasses/Frames	Partial/Annual	Lowers expense for eyewear
Contact lenses	Partial/Annual	Helps pay for replacements
Corrective surgery*	Some plans/discount	Potential savings on LASIK

Disability insurance

Disability insurance to replace income lost if you can’t work due to illness or injury. They are short and long term. Short term plans tend to encompass a couple of months, with long term ones spanning years or until retirement.

Some folks get coverage at work, some just buy their own. Disability insurance is a crucial element of financial planning. Without it, a health issue could translate into lost wages and difficulty covering bills, especially if your recovery is prolonged.

For many, missing a single paycheck is hard, and an extended hiatus can zap savings quickly. Our best plans provide peace of mind by paying a percentage of your income while you’re recovering, so you can concentrate on healing — not simply getting by.

Choosing supplemental coverage

It’s wise to consider your own personal needs, occupation and family background before selecting a plan. Costs, coverage limits and what’s left out can vary from plan to plan.

A few begin on Jan. 1, while others begin shortly after you enroll. Extra coverage may pay you, not just your doctor.

Conclusion

Choosing health insurance still seems hard, armed with the correct information, it becomes much simpler. Plans change quick, options seem infinite, having the fundamentals down is helpful. People have the option of employer-based plans, private plans or government assistance. Upfront costs, what’s covered, and when to sign up—these are the things that matter most. Most people combine base plans with additional coverage, such as dental or vision, for increased peace of mind. Even minor adjustments to your plan can save cash or include more coverage. Health insurance in the U.S. Continues to move, but solid data pierces the hullabaloo. Wish to keep on top of news and advice? Compare plans, check trusted sources and talk with local experts to find a plan that fits real life.

Frequently Asked Questions

What are the main types of health insurance in the United States?

The primary categories include employer-sponsored health insurance, individual Marketplace plans, Medicaid, Medicare, and military or veterans’ plans, each with distinct coverage details and eligibility terms.

Where can I buy health insurance in the U.S.?

You can obtain health insurance from your employer, the federal or state Marketplace, private insurance companies, or government programs such as Medicaid and Medicare.

How much does health insurance cost in the U.S.?

Rates for health care coverage vary based on your plan, age, location, and income, including monthly premiums and out-of-pocket expenses like deductibles, copays, and coinsurance.

When can I enroll in a health insurance plan?

You’re welcome to sign up for health care coverage during the yearly Open Enrollment Period or be eligible for Special Enrollment following certain life events, such as losing other coverage or welcoming a new baby.

How are modern health insurance plans changing?

Most health plans now include telehealth, mental health, and wellness benefits, while digital tools and flexible networks simplify access to health care coverage and management like never before.

What is supplemental health insurance?

Supplemental insurance provides essential health benefits to cover expenses that standard health insurance doesn’t, such as dental, vision, or critical illness services, reducing your out-of-pocket costs.

Do I have to pay a penalty for not having health insurance?

There’s no federal penalty for being uninsured, but certain states, including California, mandate health care coverage and can impose a penalty in the absence of a health plan.