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Introduction Health insurance, intended to reduce financial burdens and enhance affordability of healthcare services, remains a relatively new concept in Nigeria. Despite efforts to expand its coverage, approximately 90% of Nigerians lacked health insurance as of 2024. This study assessed the awareness, utilization, and the socioeconomic and healthcare factors influencing health insurance uptake in Ilorin, Kwara State. Method The study employed a cross-sectional design conducted among adults from the ages of 18 years and 70 years within Ilorin, Kwara State, Nigeria. Data was collected within the period of 3 months (July to September 2024) using semi-structured questionnaires covering the awareness, utilization and associated factor to health insurance uptake. Descriptive statistics, chi-square and logistic regression were conducted using SPSS version 25.0 whilst setting statistical significance with p-values at ≤ 0.05. Result Of the 415 participants, 243 (59.3%) were aware of health insurance, but only 121 (29.9%) are enrolled, with healthcare providers (37.4%) being the main source. The National Health Insurance Authority (NHIA) has the highest enrollment rate (51.2%). Among the insured, the most reported challenge was limited coverage for certain conditions (22.5%), while the uninsured mostly reported lack of awareness of available plans (33.3%). However, being a healthcare worker significantly increased awareness of health insurance (AOR = 2.368, 95% CI: 1.446–3.878, p = 0.001); single individuals showed (AOR = 0.366, 95% CI: 0.190–0.704, p = 0.003) lesser awareness. Additionally, those who were aware of health insurance were more likely to enroll (AOR = 13.893, 95% CI: 6.637–29.080, p = 0.000) and being a healthcare worker was not significantly linked to enrollment (AOR = 0.913, 95% CI: 0.538–1.549, p = 0.737). Conclusion Despite moderate awareness of health insurance, actual enrollment remained low, driven more by perceived healthcare access and system confidence than by knowledge or affordability. Limited coverage and low enrollment further hinder uptake. Targeted interventions addressing socio-economic and healthcare system barriers are essential to improve health insurance utilization and advance progress toward Universal Health Coverage (UHC).