Understanding health insurance
What is health insurance?
Health insurance is a way to pay for health and medical care. It covers and helps you manage health benefits, and medical care and treatment for illness and accidents. Your health insurance could protect you from unexpected and high costs due to a hospital stay or treatment, potentially helping you to pay for some or all the cost of this care.
Health insurance is also known as a health plan or "benefit program". You pay a monthly fee or a "premium" to keep your health insurance.
Your health insurance benefit plan documents will show the services that your insurance plan pays for or "covers". There are also "non-covered services" or services that your insurance plan does not pay for.
Why have health insurance?
Health insurance protects you from unexpected and high costs due to a hospital stay or treatment for an injury or when you are sick. Your health insurance plan could help pay for some or even all of these costs.
How does health insurance work?
The insurance carrier pays a portion of your medical costs with the premium money from all the people they insure. In the same way, your premium helps pay medical costs for others when they need it. You lose your insurance if you do not pay your premium.
What is a deductible in health insurance?
A deductible is the amount you are required to pay for covered healthcare services before your insurance plan begins to pay.
For example, if your deductible is $2,000, you will pay the cost of the first $2,000 in services. Your insurance plan pays for your claims after you have paid the first $2,000 in medical costs. Some services will be paid even though you have not met your deductible. Preventive and other wellness screenings may be covered before you meet your deductible.
What other costs, besides premium, could I have on my health plan?
A "copayment" or "copay" is another out-of-pocket cost you may need to pay. The copay is the fee that you pay at the doctor or facility office, or for medications.
You may also have "coinsurance" or "cost-sharing" costs. Coinsurance is the cost you pay for a medical service when you get it. Coinsurance applies after you reach your deductible. For example, if your health plan has a 20% coinsurance, you pay $20 of a $100 doctor bill. The insurer pays the remaining $80.
Navigating health insurance terminology
Here are simple explanations of common terms that health insurance companies use:
- Coinsurance: Percentage of cost you pay for covered healthcare services after deductible is met.
- Copay: Fixed amount you pay at the time of service for covered healthcare services.
- Deductible: The annual amount you pay for covered healthcare services before your plan begins to pay.
- Out-of-pocket (OOP) costs: Costs you pay (versus what your plan pays) for healthcare services.
- Premium: Amount you pay monthly for your insurance coverage.
- Maximum out-of-pocket (MOOP): The annual maximum amount of out-of-pocket costs that you or your family are required to pay for covered services.
For a full list of health insurance terms, please visit our glossary.
Choosing the right plan for you
Selecting the right health insurance plan for you and your family is an important decision. We offer a range of plan types that vary across the 21 counties that we serve. Our team is ready to help you select the right plan.
Essential care at all coverage levels
Every individual/family coverage plan covers these essentials:
- Adult and pediatric preventive care.
- Chronic and disease management.
- Emergency care.
- Hospitalization and outpatient services.
- Laboratory services.
- Maternity and newborn care.
- Mental health and substance use disorder services.
- Pediatric dental and vision care.
- Prescription drugs.
- Rehabilitative services and devices.
Gold, Silver, and Bronze health insurance plan categories
Each health plan is named for a metal color, which also signifies the level of coverage.
Gold |
Silver |
Bronze |
Catastrophic |
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For more information about the plans available to you, shop for a plan or see which plan types are available in your county.
How to understand exchange plans:
Think about the premium price that will work best for your budget. Your premium will be lower if you choose to pay more when you go for doctor visits or medications. The premium will be higher if you choose to pay less at the time of a doctor visit or for medicine.
What is Pennie?
Pennie is the official health and dental insurance marketplace for Pennsylvania. If you are getting health insurance for you or your family, instead of through an employer or government program like Medicare or Medicaid, you can browse our plans there. We offer several different affordable plans with various benefits so that you can find the best option for you.
Are there any ways to save on my health insurance?
Many residents of Pennsylvania qualify for tax credits and cost-sharing reductions through Pennie. Shop for coverage through Pennie to see if you qualify for these cost savings.
Can I apply directly through Capital Blue Cross for insurance?
If you are not eligible to save money by purchasing through Pennie, shop directly with us to learn about additional plan choices.
How to enroll in Capital Blue Cross health insurance plans?
Whether you're looking for individual health insurance plans or family options, Capital Blue Cross makes it easy to shop for health insurance coverage.