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Abstract Background Health insurance is an essential aspect of healthcare. This is because it enables the insured to acquire timely and essential healthcare services, besides offering financial protection from catastrophic treatment costs. This paper seeks to establish gender differentials and determinants of health insurance coverage in Zambia. Methods The data used in this study was obtained from the 2018 Zambia Demographic and Health Survey. Data were analyzed using STATA 13.0 software and focused on descriptive and Probit regression analyses. Results The study reveals that for women and men, age, wealth category, education, and professional occupation are positively associated with health insurance while being self-employed in the agricultural sector negatively influences health insurance coverage for both sexes. Other variables have gender-specific effects. For instance, being in marital union and having a clerical occupation increases the probability of having health insurance for women while being in the services, skilled, and unskilled manual occupations increases the probability of having health insurance for men. Further, residing in rural areas reduces the probability of having health insurance for men. Conclusion The study concludes that there are differences in factors that influence health insurance between women and men. Hence, this study highlights the need to enhance health insurance coverage by addressing the different factors that influence health insurance coverage among men and women. These factors include enhancing education, job creation, diversifying insurance schemes, and gender consideration in the design of National Health Insurance Scheme.