How coverage works here: United States.

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How coverage works here: United States

Handout · moraph.org/commons/sessions/reach/how-coverage-works-here

This sheet explains how health care gets paid for, in general and where you live. It is general information, not medical advice or advice on choosing a plan.

Four ways care gets paid for

A public system, paid for through taxes.
Public programs for particular groups.
Insurance, through work or bought yourself.
Paying yourself at the point of care.

The words

Premium: what you pay to be covered.
Deductible or excess: what you pay before cover starts.
Co-payment or coinsurance: your share of each visit or prescription.
Out-of-pocket cost: anything you pay yourself.

Before you get care, ask

Is this covered, and is anything not?
Do I need a referral or a particular provider?
What will I pay, and does anything need approval first?

Stay safe

If it might be an emergency, call the emergency number first.
Real programs don’t cold-call to sell cover or ask for your details.
Check anything you’re unsure about on the official sites below.

In the United States

A mix of programs and insurance. Many people get insurance through work. Medicare covers people 65 or older who meet citizenship or residency rules, and some younger people with a disability. Medicaid and the Children’s Health Insurance Program (CHIP) give free or low-cost coverage to some people on low incomes, families, children, pregnant women, older people and people with disabilities.
Medicaid differs by state. Medicaid follows federal rules, but who qualifies, what it covers and what it costs differ from state to state. You can apply for Medicaid and CHIP at any time of year, through HealthCare.gov or your state Medicaid agency.
The Marketplace. HealthCare.gov is the government’s Health Insurance Marketplace for people buying their own plan. A premium tax credit can lower the monthly premium, depending on household income. To use the Marketplace you must live in the US, be a citizen, national or lawfully present, and not be incarcerated.
When you can sign up. Outside the yearly Open Enrollment Period, you can only enroll in or change a Marketplace plan if you qualify for a Special Enrollment Period, after certain life changes such as losing other coverage, moving, getting married or having a baby, usually within 60 days.
Free help to apply. Navigators are trained to help people look for coverage and fill in Marketplace forms. They must be unbiased and their help is free. HealthCare.gov has a tool to find local help.
If a claim is refused. If your health plan refuses to pay a claim or ends your coverage, you have the right to appeal and have the decision reviewed by a third party.

Official places to check:

HealthCare.gov (US Centers for Medicare & Medicaid Services): www.healthcare.gov/medicaid-chip
Medicare.gov (US Centers for Medicare & Medicaid Services): www.medicare.gov/basics/get-started-with-medicare
HealthCare.gov (US Centers for Medicare & Medicaid Services): www.healthcare.gov/quick-guide/eligibility
HealthCare.gov (US Centers for Medicare & Medicaid Services): www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period
HealthCare.gov (US Centers for Medicare & Medicaid Services): www.healthcare.gov/glossary/navigator
HealthCare.gov (US Centers for Medicare & Medicaid Services): www.healthcare.gov/glossary/appeal

General information, not advice about your own situation. Checked 19 October 2026. If an official source says something different, it is right. Free to copy and adapt. moraph.org/commons/sessions/reach/how-coverage-works-here