Background <p>Health insurance is critical for achieving Universal Health Coverage and Sustainable Development Goals. In Tanzania, despite the challenges within the health system, emphasis on health insurance subscription remains inadequate. Therefore, this study aimed to understand the trends and determinants of health insurance coverage among women of reproductive age (WRA) for evidence-based interventions.</p> Methods <p>This study employed an analytical cross-sectional design using secondary data from the 2010–2022 Tanzania Demographic and Health Surveys. This study included 38,659 WRA, selected through a two-stage sampling method. Given the survey’s complex design, a multilevel logistic regression model was used to identify individual and community-level determinants of healthcare insurance coverage. Adjusted odds ratio (AOR) with 95% confidence intervals (CI) were reported.</p> Results <p>The overall prevalence of health insurance coverage among WRA in Tanzania was 7.10% (95%CI: 6.59–7.64). From 2010 to 2022, the prevalence of health insurance varies. In 2010, it was 6.48%, 9.05% in 2015/16, and 5.82% in 2022, indicating a fluctuation rather than a consistent trend over time. At the individual level, women’s age, education level, marital status, media exposure, wealth quintile, health facility visits were significantly associated with higher odds of health insurance coverage. At the community level, women in central zones had increased odds while those in Zanzibar had decreased odds of health insurance coverage.</p> Conclusion <p>This study found a notably low prevalence of health insurance coverage among WRA. A multifaceted approach emphasizing on expanding coverage among younger and economically disadvantaged women and those with limited education, media access, and geographical disparities would be essential in improving health insurance uptake.</p>