How Health Insurance Works?

May 19, 2020

A single doctor's office visit may cost several hundred dollars, and an average hospital stay of three days may cost tens of thousands of dollars (or even more) depending on the quality of treatment given.

Most of us could not afford to pay these large amounts when we get sick, particularly because we don't know when we could get sick or hurt, or how much treatment we might need. This is where health insurance comes in to provide a way to reduce these costs to more fair and sustainable rates.

One way for health insurance companies to monitor their costs is to regulate access to providers. Providers include physicians, clinics, labs, pharmacies, and other organizations. Many insurance firms partner with a designated network of healthcare providers who have agreed to provide enrolled plan services at more attractive rates.

One of the things healthcare reform has done in the United States (under the Affordable Care Act) is to bring further uniformity in medical coverage. Before such standardization, the benefits offered differed significantly from plan to plan. Some contracts, for example, included prescriptions, some did not. Plans in the U.S. are also expected to have a range of "critical health benefits" that have to include:

  • Emergency services
  • Hospitalization
  • Laboratory tests
  • Maternity and newborn care
  • Mental health and substance-abuse treatment
  • Outpatient care (doctors and other services you receive outside of a hospital)
  • Pediatric services, including dental and vision care
  • Prescription drugs
  • Preventive services (e.g., some immunizations) and management of chronic diseases
  • Rehabilitation services