Coverage Basics

Many Missourians have access to quality, affordable health insurance. Health insurance helps reduce the amount you pay for medical and emergency care. There are three important things to look at when buying health insurance:

  • The services that each plan covers, like doctor visits and medicine.
  • How much you’ll pay for the plan, called premiums.
  • How much you’ll pay for covered services, called cost-sharing.

What does health insurance cover?

Health insurance plans must cover a set of core benefits, called essential health benefits, including:

  • Ambulatory services, like visits to your doctor’s office.
  • Emergency services.
  • Hospitalizations, usually round-the-clock care for people in the hospital.
  • Maternity and newborn care for pregnant women, new moms, and their babies. These services include breastfeeding pumps, well-baby visits, and gestational diabetes screenings to help keep moms and babies healthy.
  • Mental health and substance use disorder services, including counseling to treat depression and alcohol abuse.
  • Prescription drugs.
  • Rehabilitation and habilitative services. Rehabilitative services may include physical therapy, occupational therapy, or walkers to aid in recovery following an illness or injury. Habilitative services include things like hearing aids that allow people to keep or get a skill important for daily living.
  • Laboratory services, like blood tests your doctor uses to diagnose and treat you.
  • Preventive services and chronic disease management to help prevent and control continuing conditions. Services may include:
    • Cancer screenings and check-ups.
    • Programs to help you quit smoking.
    • Pediatric services for kids and babies, including dentist visits and eye exams.

Some plans may also include more benefits than what they are required to cover by law. Insurance companies cannot put lifetime limits on essential health benefits, but they can still place limits on nonessential benefits. For example, your health plan can limit how much it will cover for dental care each year or over your lifetime, because dental care for adults is not an essential health benefit.

How does health insurance work?

Health insurance helps pay for the cost of medical care by reducing the amount you personally pay when you have medical needs. The amount you pay depends on your specific health insurance plan. Most health plans use a combination of the following:

  • Premiums – A premium is a set amount you pay for your health insurance plan, usually paid every month. You pay your premium even if you don’t receive medical care that month.
  • Deductibles – A deductible is the amount of money you pay for health care services before your insurance plan will begin to pay for covered health services. For example, if your health insurance plan has a $1,000 deductible, you must pay $1,000 for medical care before your insurance will start paying. A deductible may not apply to all health services, such as preventive care.
  • Co-payment – A co-payment, also called a co-pay, is a fixed amount you will pay for medical services. For example, you may pay $25 every time you visit your doctor. Your health plan will pay the rest of the amount for that visit.
  • Coinsurance – Coinsurance is a type of payment where you pay a percentage of the cost for a covered health service. For example, if your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%, you would pay $20. Your health insurance plan pays the rest. The coinsurance percentage depends on your specific insurance plan.

Health insurance protects you from the high costs of health care. Without insurance, people who experience a medical emergency or require routine care to manage a health condition can go deep into debt or even bankruptcy.

How do I choose a health plan?

To choose the health plan that is best for you and your family, visit the Missouri Health Insurance Marketplace. On this website you will be able to compare and buy a plan that fits your needs. You will also be able to see if you qualify for financial help.

Choosing the right health insurance plan is important. Not every person or family has the same needs or available resources. The Missouri Health Insurance Marketplace offers a variety of health plans that are designed to meet different health care needs and budgets. Individuals and families can use this calculator to see how much they might be able to save.

How much does health insurance cost?

Many people who want health insurance are concerned about cost. All insurance plans available through the Missouri Health Insurance Marketplace will be offered by private insurance companies. Some Marketplace health plans will have lower premiums and require you pay more out-of-pocket when you need care. Some plans will have higher premiums that cover more of your costs when you need care. Others will be in the middle. All plans will cover the same essential health benefits.

People seeking health coverage through the Missouri Health Insurance Marketplace may get financial help depending on their income. To learn more about financial help for individuals and families, click here.