Understanding health insurance pricing in the U.S.

Learn more about how health insurance pricing is determined, and how it affects you.

Jeremy Wolf

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Jeremy Wolf

Adam Stevenson

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Adam Stevenson

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Health insurance in the United States is a complex system with varied pricing mechanisms. We'll explores the intricacies of health insurance carrier pricing, including what insurance covers and how it operates. Topics like insurance premiums, deductibles, copays, and the role of employer sponsors in group health plans are discussed to provide a comprehensive understanding of how health insurance costs are determined and what they mean for consumers.

Understanding Health Insurance in the United States

Health insurance is an essential part of the American healthcare system, providing financial coverage for medical expenses to individuals and groups. The primary function of health insurance is to mitigate the economic impact of healthcare costs, which can be prohibitively expensive without insurance coverage. The insurance system is characterized by a blend of private and public insurance programs, with varying coverage options, premiums, and benefits.

There are several types of health insurance plans, such as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), and Point of Service (POS) plans. Each type offers different levels of flexibility in choosing healthcare providers and services, which significantly impacts their pricing.

How Does Health Insurance Work?

Health insurance operates on the principle of risk pooling. Insurers collect premiums from a large group of people (policyholders) to create a pool of funds. These funds are then used to pay for the healthcare expenses of those in the pool who need medical care. The risk of incurring high medical costs is thus shared among all policyholders, making healthcare more affordable for everyone in the pool.

What Does Health Insurance Cover?

At its core, health insurance covers a range of medical expenses. These typically include doctor's visits, hospital stays, emergency room visits, surgeries, and prescription medications. Some plans also cover preventive services like vaccinations and health screenings. The extent of coverage can vary significantly between different insurance policies, influenced by factors like the type of plan, the insurance provider, and the level of premium paid.

Determining Health Insurance Pricing

The pricing of health insurance is a complex process influenced by various factors:

  • Risk Assessment: Insurers assess the risk of potential medical costs based on factors like age, gender, medical history, and lifestyle. Higher-risk individuals generally face higher premiums.

  • Plan Type: The type of health insurance plan (such as HMO, PPO, or EPO) influences pricing. Each plan offers different levels of flexibility in choosing healthcare providers and services, impacting the cost.

  • Coverage Level: Plans with more comprehensive coverage and lower out-of-pocket costs typically have higher premiums.

  • Location and Regulations: Health insurance costs vary by state due to differences in state regulations and the cost of living.

  • Competition and Market Forces: In areas with more insurance providers, competition can drive down prices. Conversely, less competition often leads to higher prices.

  • Out-of-pocket costs: They are affected by factors like co-insurance, deductibles, and copays. The relationship between these elements determines the overall financial responsibility of the policyholder.

In-Network vs. Out-of-Network Provider Cost Comparisons

A critical aspect of health insurance pricing is understanding the difference between in-network and out-of-network providers:

  • In-Network Providers: These are healthcare professionals who have agreed to provide services at lower, negotiated rates with the insurance company, resulting in lower costs and better coverage for the insured.

  • Out-of-Network Providers: These providers do not have a contract with the insurance company, often leading to higher costs for the patient and potentially limited or no coverage from the insurance.

Example: Consider a medical procedure with a standard cost of $1,000:

  • In-Network: Negotiated rate might be $700. If the insurance covers 80%, it pays $560, leaving the patient to pay $140.

  • Out-of-Network: The provider charges the full $1,000. If insurance covers 50%, it pays $500, and the patient is responsible for the remaining $500, plus any additional balance billed by the provider.

This comparison underscores the importance of choosing in-network providers whenever possible to minimize healthcare costs.

Role of Employer Sponsors in Group Health Plans

In 2022, employment-based insurance was the most common type of health insurance coverage in the United States, covering 54.5%. Additionally, 53% of all workers were covered by health plans offered by their employer, known as group health plans​​. These plans are generally more cost-effective due to the employer sponsor covering a portion of the insurance premium, leading to lower costs for employees. Additionally, the risk is spread over a larger group, potentially reducing the overall premium per individual.

Some Useful Health Insurance Definitions

  • Insurance Premiums: The insurance premium is the amount paid by or on behalf of the policyholder to maintain insurance coverage. Premiums can be paid monthly, quarterly, or annually and are determined based on the factors mentioned above. For employer-sponsored group health plans, the premium is often shared between the employer and the employee, reducing the financial burden on the latter.

  • Deductibles: A deductible is the amount a policyholder must pay out of pocket for covered healthcare services before the insurance plan starts to pay. Plans with higher deductibles generally have lower monthly premiums, as the policyholder assumes more of the cost burden upfront. Conversely, plans with lower deductibles have higher premiums.

  • Copays: A copay is a fixed amount paid by the policyholder for specific services, such as a doctor's visit or prescription medication, under their health insurance plan. Copays are one way in which the cost of healthcare is shared between the insurer and the insured, and they vary depending on the plan and the type of service.

How does Thatch Insurance Pricing Process Work?

As we stated, health insurance pricing can often seem complex and opaque. Here's how we handle it on Thatch:

  • Direct carrier data: The prices displayed on Thatch are directly obtained from the insurance carriers. This means the price you see is the same as what you would find if you approached the carrier directly.

  • No markup policy: At Thatch, we do not add any additional fees to the premium prices. The amount you see is the unaltered premium set by the insurance carrier.

How We Ensure Price Accuracy

We take a few steps to ensure that the prices you see on Thatch are accurate and up-to-date:

  • Data verification: We regularly verify the pricing data provided by the carriers to ensure that what you see on Thatch is the most current and accurate.

  • Handling price discrepancies: In rare cases where the carrier-provided price is incorrect or changes after being listed, we take immediate steps to update our listings. You will only be charged the correct amount as determined by the insurance carrier.

Why Use Thatch for Price Comparisons

You can compare health insurance plan prices on our plans page. Here's why you should use Thatch for your health insurance price comparisons:

  • Simplicity: Thatch simplifies the process of comparing health insurance prices from various carriers, all in one place.

  • Transparency: Our commitment to transparency means that you have access to straightforward and honest pricing information.

  • Consistency: With Thatch, you are guaranteed to pay the same price as you would if you purchased the plan directly from the carrier.

Understanding Pricing on Thatch

Understanding health insurance pricing is crucial in making informed decisions about your healthcare coverage. At Thatch, we provide transparent, accurate, and fair pricing to help you choose the best plan for your needs. Remember, the price you pay on Thatch is the same as going directly to the carrier – with no hidden fees or markups. More on how pricing works here.

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Written byJeremy WolfCustomer Success and Broker Operations Lead at Thatch

Jeremy Wolf, former professional athlete, is dedicated to enhancing healthcare access. As Customer Success and Broker Operations Lead at Thatch, Jeremy focus on providing customers with everything they need to navigate the complex health insurance space.

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