Health Insurance 101

Health insurance helps you pay for your health care needs and costs. Having health insurance ensures that when illnesses and injuries occur you can get the care that you need without being burdened by the overwhelming costs of treatment. But what do we really know about health insurance? This blog will attempt to answer some frequently asked questions about health insurance.

Q and A Session with and

Q: Why get health insurance?

A: High medical bills can put a family into financial crisis causing extreme debt or even losing their home. Some people will not go to get health care when they need it because of the high costs, and not receiving the treatment you need can result in becoming more ill or even cause death.

Did you know? A broken arm without health insurance can cost more than $7,500, and a three-day stay in the hospital can cost more than $30,000.

Q: What are the benefits to having health insurance?

A: You and your insurance company share the health care costs. By making consistent payments towards your health insurance, the company will pay for your medical bills when you get sick or hurt. Depending on your health insurance coverage, the company may work with hospitals and care providers to reduce medical costs.

Q: What is the Affordable Care Act?

A: The Affordable Care Act (ACA), is a new law that ensures that everyone can have access to some form of health insurance. Health insurance can be built around the needs and budget of individuals and families. You are guaranteed health insurance coverage even if you are sick or injured. All health insurance plans must cover the costs of doctor visits and prescriptions, however there might be a copay required depending on your coverage.

Did you know? Everyone is required to have a health insurance policy. There are penalties for not having health insurance including paying a fine.

Q: What do you mean by being charged a fine for not having health insurance?

A: In 2015, the fine for not having health insurance is $325 per adult and $162.50 per child or 2% of your income, whichever is more. Exceptions to the fine include: when your income is too low that you don’t even have to file a federal tax return, if you are in prison, if you have a religious objection, if you can’t afford it, if you are an undocumented immigrant, or if you are a member of an Indian tribe.

Q: What is the Health Insurance Marketplace?

A: The Marketplace will help you learn about the health insurance plans you qualify for, and will help you get your own health insurance plan. You can visit or for more information about the Marketplace and health insurance coverage. The Marketplace can help you if: you don’t have health insurance, you are choosing a health insurance plan, you can’t get, or can’t afford, the health insurance provided through your job, you own a small business, or you need free or low-cost health insurance. You can apply by phone, online, or by mail.

Did you know? The Marketplace can connect you to a Navigator/Assister in your community that can answer your questions and guide you through the sign-up process.

Q: What types of plans are offered in the Health Insurance Marketplace?

A: The Platinum plans will cost more every month, but will have lower out-of-pocket costs. Bronze plans will have a lower monthly fee, but will have higher out-of-pocket costs. Each of these plans are called the Qualified Health Plan.

Q: What do Marketplace Health Insurance Plans cover?

A: They cover: regular doctor visits, emergency room visits, hospitalizations, pregnancy, giving birth, newborn care, mental health care, substance and alcohol abuse treatment, medicines, rehabilitation, X-rays and other tests, preventative care, and care for children, including dental visits. Some qualified health insurance plans will cover more of these services than others.

Q: What kind of financial help might be available?

A: If you buy health insurance through the Marketplace, you may be eligible for financial assistance. This is determined by how much money you make, the size of your family, your citizenship status, whether you are in jail or prison, and where you live. See the chart below for information on who might qualify based on family size and income.

Family Size

May Qualify if Income is Below













*(Income given is an approximated value.)

Did you know? In 2014, 4 out of 5 people who signed up for health insurance through the Marketplace received financial assistance. Their average monthly cost was about $82.

Q: What is the difference between Medicaid and Medicare?

A: Medicaid is health insurance for adults, children and families with low incomes, and some senior citizens and people with disabilities. It’s free or low-cost coverage for those who need it. Medicare is health insurance for people 65 years and over.

Q: What is the Children’s Health Insurance Program (CHIP)?

A: CHIP is health insurance for children and teens under the age of 19. To qualify for this it depends on how much income the family has. This would be free or low-cost health insurance coverage. Services covered include: checkups, shots, regular doctor visits, hospital care, dental care, eye care, and X-rays/other tests.

Q: How has the Affordable Care Act helped with the rates of uninsured people?

A: In Winnebago County, the uninsured rate in 2013 was 21% and the uninsured rate in 2014 was 12%. That means that within a year 9% more of people in Winnebago County became insured. This is partially due to the easier access to health insurance because of ACA and platforms such as the Health Insurance Marketplace. (Study done by the Kaiser Family Foundation).

Now that you are familiar with the basics of Health Insurance, we will talk about when you can start applying for your health insurance and the deadlines for getting coverage for 2016. You can apply for 2016 health insurance coverage starting on November 1st, 2015. Applying for health insurance can be done online, by phone, with in-person help, and through a paper application. Coverage can start on January 1st, 2016, as long as the application was submitted and the first month’s premium was paid by December 15th, 2015.

Need Health Insurance? Help can be found at:

  • Partnership Community Health Education Center
    (920) 882-6420

  • LAKESHORE Community Health Care
    (920) 783-6633

Sheboygan and Manitowoc

  • Family Health/La Clinica
    (920) 787-5514


  • Health Insurance Marketplace

  • Call 1-800-236-7250 to ask questions/schedule an appointment

  • Contact your local health insurance agent

  • Online at

  • Apply for BadgerCare Plus

Online at

Call 1-800-256-4563

In person at your local Health and Human Services Office


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Written By:  Amanda Hammond, OAUW Intern