understanding health insurance basics

understanding health insurance with mother holding son

private healthcare coverage can be complicated. here’s what you need to know:

what is health insurance coverage?

Health insurance coverage helps you pay for medical care and gives you access to a network of doctors and hospitals.

how does health insurance work?

First, you buy a health plan. A health plan determines the types of medical services (benefits) you are covered for, the doctors and hospitals you can visit, and how much you will pay when you get care.

When you need medical care, you visit a doctor or hospital in your plan’s provider network. A network is a group of doctors, hospitals, and healthcare providers that have agreed with the health insurance company to accept certain amounts for each service as payment in full. Your costs for care are usually lower when you use network providers compared with using non-network providers.

Healthcare coverage isn’t just for when you’re sick. Preventive care services can help keep you and your family healthy with annual health exams and immunizations such as flu shots – available at no additional cost.

what do I pay monthly?

You’ll pay a fixed monthly rate for your health insurance plan. The amount depends on the plan you choose, where you live, and the age of each person on the policy. The lower your plan’s monthly rate, the more you typically pay when you see the doctor, and vice versa. Identifying how often you see a doctor can help you choose the right plan for you.

Depending on your household size and income, you may be eligible for financial assistance through Covered California, our state’s health exchange, to lower your plan’s monthly rate or even your costs for medical care.

what do I pay when I see a doctor?

It depends on the service and your plan’s benefits. Some services have a copayment, which is a fixed dollar amount. Other services have a coinsurance, which is a fixed percentage amount. When you get care from a network* doctor, you pay the copayment or coinsurance, and the health plan pays the rest up to the allowed charges.

Some health plans have an annual deductible, which is the amount of money you pay for services before the coinsurance and health plan begins paying for them.

To protect you and your family from unexpected costs, most plans have an annual out‑of‑pocket maximum. Once you reach the out-of-pocket maximum, your health plan covers 100% up to the allowed charges for most covered medical services.

get a quote

Now that you understand the basics of health insurance coverage, take a look at our plans, get a quote, and apply for coverage today.

* Although some plans let you get care from hospitals and doctors that aren’t in the plan’s network, you’ll pay more to see those non-network providers. The plan may also have other costs – such as a separate, higher deductible – for seeing these providers. These extra costs can be very high, so it’s more cost-effective to get care from network providers.


allowed charges

The dollar amount a member’s health plan will use to calculate payment for medical services

benefits (covered services)

The medically necessary services and supplies covered by the member’s health plan.


The percentage of the allowed charges a member pays for benefits after meeting any calendar-year deductible.


The fixed dollar amount a member pays for benefits after meeting any calendar-year deductible.


The amount a member pays each calendar year for most benefits before Blue Shield begins to pay. Some benefits, such as preventive care, are covered before the member meets the calendar-year deductible.


A health plan in which members choose a primary care physician to administer their care, including referrals to specialist doctors. Covered benefits need to be received from providers in the primary doctor’s medical group. There is no coverage for services received from doctors who are not in the member’s medical group.


A group of providers - including hospitals, doctors, specialists and other healthcare providers - that have agreed with the health plan to provide benefits to plan members for a specified amount.

out-of-pocket maximum

The combined maximum of the deductible, copayment, and coinsurance amounts for all covered services an individual or family is required to pay each year.


A health plan in which members can choose to see any provider in the PPO provider network without a referral. Members also have the freedom to use non-network providers for most services if they are willing to pay a higher share of the cost.


woman smiling about individual health insurance by Blue Shield of California