If you’re reading this, you’re invested in your health. But staying healthy is complicated. Where do you start? Should you see your doctor even when you’re not sick? Will insurance cover it? What will it cost? And after the appointment – what comes next?

These are just some of the questions you face while navigating the complex American healthcare system. And since everyone’s situation is unique, it becomes even more challenging.

To help simplify this, Unbiased Science partnered with Your Doctor Friends to create a patient survival guide – think “Healthcare for Dummies” (hello, millennials). This will be an accessible, credible resource directly from board-certified physicians, a public health scientist, and a neurobiologist.

To make this relatable, we created an avatar to walk you through both simple and complex healthcare processes.

Meet Gabby, our 28-year-old friend. She was on her parent’s insurance until age 26 but spent two years uninsured while working gig jobs. Now she has a new job with benefits. But when signing up for insurance, she faces three options. What’s the difference? What do terms like deductible, in-network, max out-of-pocket, or co-pay mean? Let’s dig in!

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Your Guide to Healthcare Coverage

Our 28-year-old friend, Gabby, just landed a job with benefits and is navigating health insurance for the first time. But before we help her choose between plans, let’s step back and look at the bigger picture. Healthcare in America can feel like a maze, but understanding how people get insurance is the first step to finding your way through it.

How Do People Get Health Insurance?

The path to getting health insurance in America isn’t one-size-fits-all. There are several main routes people take to get covered, and sometimes these paths can overlap. Let’s break them down:

Employer-Sponsored Insurance
- Most Americans get insurance through their jobs
- Employers typically share the cost of premiums
- Like Gabby, you might have multiple plans to choose from
- Coverage usually extends to spouses and dependents
  1. There may be “spousal surcharges” if your spouse uses your insurance rather than their own company-offered program
  2. Costs are higher for plans including families or spouses.

This is the most common way Americans get health insurance, and it’s the path Gabby is now exploring. But what about people who don’t have this option?

Individual Market/Healthcare Marketplace

This is where Gabby was told to find coverage during her two years of gig work, though she found the premiums challenging on her variable income. What is the Marketplace?

Created by the Affordable Care Act (ACA or “Obamacare”) in 2010
Available through Healthcare.gov or state marketplaces
Designed for people without employer coverage
Features income-based subsidies (financial help) to make insurance more affordable

Let’s break down what “income-based subsidies” means: If your income falls below a certain level, the government helps pay for your insurance. Think of it like a sliding scale – the less you make, the more help you can get. These subsidies can:

Lower your monthly premium (the amount you pay each month)
Reduce your out-of-pocket costs for medical care
Make comprehensive coverage affordable for many who couldn’t otherwise afford it

The Marketplace was created to ensure everyone has access to quality health insurance, regardless of their employment status or pre-existing conditions. It’s particularly important for freelancers, small business owners, and people between jobs.

Medicare
- Federal program for people 65 and older
- It also covers some younger people with disabilities
- Different parts cover different services:
  - Part A: Hospital insurance
  - Part B: Medical insurance
  - Part C: Medicare Advantage plans
  - Part D: Prescription drug coverage
Medicaid
- State-federal program for low-income individuals
- Eligibility varies by state
- Usually, there is low or no cost to participants
- Comprehensive coverage including preventive care

An important note about Medicare and Medicaid: Some people qualify for both programs. These “dual eligible” individuals are typically:

Older adults with limited income and resources
People with disabilities who have limited income
People who need long-term care services

Being dual eligible can provide more comprehensive coverage than either program alone, as Medicaid can cover services that Medicare doesn’t, like long-term care and some home health services. For example, if someone needs nursing home care, Medicare might cover the first 100 days, but Medicaid could help with longer-term care needs.

Other Options
- CHIP (Children’s Health Insurance Program)
- Military/VA healthcare
- Student health plans
- Parent’s insurance (until age 26)

Types of Insurance Plans

Now that we know HOW people get insurance, let’s look at the different TYPES of plans they might encounter. Think of these as different styles of coverage – each with its own rules about how you can get care and what you’ll pay:

HMO (Health Maintenance Organization)

Lower monthly premiums
Must choose a primary care physician (PCP)
Need referrals for specialists and may be excluded from seeing some providers
Only covers in-network care except in emergencies
More coordinated care
Providers/Health Organizations are paid a lump sum up-front for caring for a whole group of people. The incentive is to keep costs down by limiting unnecessary care. By using less care, the providers can “keep” more money.
- In general, this is less desirable for the provider and also can lead to organizations aiming to attract healthier patients and potentially referring out “higher utilizers” of healthcare.

Important Note: While HMOs might seem perfect for “healthy” people due to lower costs, remember that health needs can change unexpectedly. A sudden illness, accident, or new diagnosis could mean needing specialists and coordinated care. What seems like a money-saver today could become limiting when you really need options.

PPO (Preferred Provider Organization)

Higher monthly premiums
See any doctor without referrals
Coverage for both in and out-of-network care
More flexibility but higher costs
Less coordinated care
Services are billed on a fee-for-service model. Each visit or procedure is billed separately and reimbursed to the provider. Therefore there is more incentive for the provider to “do more.”
- This is generally the preferred model for providers as they have more freedom to order tests and procedures they see fit and are reimbursed for their work.

EPO (Exclusive Provider Organization)

Hybrid between HMO and PPO
No need for referrals
Only covers in-network care
Often lower premiums than PPOs

High-Deductible Health Plans (HDHP)

Very low monthly premiums
Very high deductibles
Often paired with Health Savings Accounts (HSAs)
Can be risky if unexpected health issues arise

Understanding Different Types of Care

Healthcare services generally fall into several categories, and coverage can vary for each. Understanding these differences helps you know what to expect when seeking care:

Preventive Care

Usually covered 100% with no cost to you
Annual check-ups
Vaccinations
Screening tests (mammograms, colonoscopies, etc.)
Many contraceptive services

These services are designed to keep you healthy and catch potential problems early, which is why insurance companies usually cover them in full.

Routine Care

Regular doctor visits
Management of chronic conditions
Usually subject to copays or coinsurance
Might need to meet the deductible first
Shares several procedures with preventive care

This is the everyday healthcare most people need throughout the year.

Urgent/Emergency Care

Higher copays/coinsurance than routine care
Emergency care is usually covered at any hospital
Urgent care centers are often cheaper than ERs
Always covered for true emergencies, regardless of network (thanks to something called EMTALA)

It’s important to know your options here – an urgent care visit might save you hundreds compared to an ER visit for non-emergency situations.

Specialty Care

Often more expensive
Might need referrals (especially with HMOs)
Usually higher copays
May require prior authorization

Think of specialists as healthcare experts for specific conditions or parts of the body.

Mental & Behavioral Health Care

Like Gabby, who wants to be proactive about her health, many people seek occasional therapy for stress management and preventive mental healthcare.

Required to be covered by most plans
May have separate deductibles/copays
This can include therapy, counseling, medications, and substance use disorder treatment
Network restrictions may apply

Thanks to recent laws, mental and behavioral health care must be covered similarly to physical health care.

Real-World Example: Back to Gabby

Let’s say Gabby is “healthy” but:

Has a family history of breast cancer
Occasionally gets migraines
Wants to start a family in the next few years

Her healthcare needs might include:

Annual preventive check-ups (covered 100%)
Regular breast cancer screenings (preventive)
Potential neurologist visits for migraines (specialty care)
Future prenatal care (specialty/maternity care)

Even though she’s healthy now, choosing a plan means thinking about:

Access to specialists if needed
Coverage for potential future needs
Cost balance between premiums and out-of-pocket expenses
Network adequacy for various types of care

Making Your Choice

When selecting insurance, consider:

Current health needs
Family history
Future plans (travel, starting a family, etc.)
Financial situation
Preferred doctors and hospitals
Prescription medication needs
Worst-case scenarios

Remember: The “cheapest” plan isn’t always the most affordable in the long run. Consider total potential costs, not just monthly premiums.

The Monthly “Membership Fee”: Your Premium Think of your premium like a monthly subscription fee—it’s what you pay to keep your insurance active. Just like how you pay for Netflix whether you watch it or not, you’ll pay your premium whether you use your insurance that month or not. For Gabby, this means looking at how much she can afford to pay each month from her new salary.

The “Down Payment”: Your Deductible Your deductible is like a down payment on your healthcare for the year. Let’s say Gabby’s plan has a $1,500 deductible. This means she needs to spend $1,500 of her own money on covered healthcare services before her insurance starts pitching in. It’s like having to spend $50 at the grocery store before your coupons kick in—except with much bigger numbers!

The “Cover Charge”: Co-pays After meeting her deductible, Gabby will still have to pay something called a co-pay. Think of this as a cover charge for healthcare services. It’s usually a fixed amount—maybe $25 for a regular doctor visit or $40 to see a specialist. The good news? It’s predictable, so Gabby can budget for it.

Sharing the Bill: Co-insurance Sometimes instead of a fixed co-pay, Gabby might have to pay co-insurance. This is like splitting the bill at dinner, but instead of going 50-50, the insurance company usually pays most of it. For example, with 20% co-insurance, if a procedure costs $100, Gabby pays $20 and her insurance covers $80.

Your Financial Safety Net: Out-of-Pocket Maximum This is actually good news! The out-of-pocket maximum is like a spending cap for the year. Once Gabby hits this limit, her insurance picks up 100% of covered costs for the rest of the year. It’s her insurance company saying, “OK, you’ve spent enough—we’ve got it from here.”

Making the Choice: Gabby’s Decision

Looking at her options, Gabby weighs her needs against the available plans:

Plan A – High Deductible Health Plan (HDHP)

Lowest premium: $150/month
$3,000 deductible
HSA eligible
Limited network

Plan B – EPO

Mid-range premium: $250/month
$1,500 deductible
Broad network, but in-network only
No referrals needed

Plan C – PPO

Highest premium: $350/month
$1,000 deductible
Most flexible network
Includes out-of-network coverage

Considering her migraine history, family history of breast cancer, and plans to start a family in the next few years, Gabby chooses Plan C. The PPO’s flexible network means she can find the right specialists for her care while having the freedom to seek second opinions if needed – making the higher premium worthwhile for her situation.

Remember: Your choice might be different. Like Gabby, consider your health needs, budget, and future plans when selecting coverage. This is your selection for this year ONLY, so track your healthcare usage throughout the year. You can use this information to help you make your selection next year.

Like Gabby, you now have the foundational knowledge to navigate the complexities of healthcare coverage confidently. While the system isn’t perfect, understanding these basics will help you make informed decisions about your care.

P.S. Even with our combined medical degrees, PhDs, and years of working in healthcare, we still sometimes struggle to navigate the insurance system. If you find it confusing, you’re not alone! We created this guide because we believe healthcare shouldn’t be so complicated. We hope it helps make your journey a little easier.

Coming up next in our Patient Survival Guide: “Making the Most of Your Insurance: A Year in the Life” – where we’ll share practical strategies for maximizing your benefits and avoiding common pitfalls.

Stay curious,

Unbiased Science and YDF

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Written by the physicians and scientists of Unbiased Science and Your Doctor Friends, dedicated to making health science more accessible for everyone.