How Health Insurance Works

Health insurance is a contract between you and an insurance provider that helps cover the cost of medical care. In exchange for regular payments, called premiums, the insurance company shares the cost of medical services like doctor visits, hospital stays, medications, and preventive care. While health insurance reduces your financial burden for these services, it does not cover everything, and certain out-of-pocket expenses, like deductibles, co-pays, and coinsurance, still apply. We’ll discuss these terms in detail below. It’s also important to note that health insurance is not a direct healthcare provider—it’s a system to help manage costs, not the source of medical care itself.

As of November 1, 2024, Georgia transitioned from using the federal HealthCare.gov platform to its own state-based health insurance marketplace called Georgia Access.

This platform allows residents to shop for, compare, and enroll in health insurance plans tailored to their needs.

Applying for Health Insurance in Georgia:

1. Access Georgia Access:
   • Visit the official Georgia Access website at georgiaaccess.gov.
2. Create an Account:
   • Click on the “Get Covered” button to begin.
   • Follow the prompts to create a new account by providing your personal information, including your name, email address, and creating a secure password.
3. Complete the Application:
   • Once your account is set up, log in to start your application.
   • Provide detailed information about your household, income, and any current health coverage.
   • The system will assess your eligibility for various health coverage options, including Medicaid and financial assistance programs.
4. Review and Select Plans:
   • After determining your eligibility, you’ll be presented with a range of health insurance plans.
   • Compare the available options based on coverage details, premiums, deductibles, and other factors to choose the plan that best suits your needs.
5. Enroll:
   • Once you’ve selected a plan, follow the instructions to enroll.
   • Be mindful of enrollment deadlines to ensure your coverage starts as needed.

A deductible is the amount you must pay out of pocket for covered healthcare services before your insurance begins to pay. For example, if your plan has a $1,000 deductible and you need surgery that costs $3,000, you’ll pay the first $1,000. After that, your insurance covers a portion of the remaining $2,000, depending on your plan’s terms. Preventive services, like annual checkups, are often exempt from the deductible and covered entirely by your plan.

A co-pay is a fixed amount you pay for specific healthcare services or prescriptions at the time of your visit. For instance, you might pay $25 to see your primary care doctor or $50 to visit a specialist, regardless of the total cost of the service. If you pick up a prescription, your co-pay might be $10 for a generic medication or $30 for a brand-name drug, depending on your insurance plan.

Coinsurance is the percentage of costs you pay for a covered healthcare service after meeting your deductible. For example, if your plan requires 20% coinsurance and a hospital stay costs $10,000, you would pay $2,000 (20% of $10,000) while your insurance covers the remaining $8,000. Coinsurance typically applies to services like hospital stays, MRIs, or outpatient procedures.

Preventive care includes routine healthcare services aimed at preventing illnesses or detecting health issues early when they are easier to treat. Examples include annual physical exams, vaccinations, screenings like mammograms or colonoscopies, and counseling for lifestyle changes such as quitting smoking. Most health insurance plans cover preventive care services at no cost to you, meaning you won’t pay a deductible, co-pay, or coinsurance for these services as long as you use an in-network provider. For instance, you could get a flu shot or a cholesterol screening without any out-of-pocket expenses under most plans.