Most Americans get health insurance through their employer, Medicare, or Medicaid. however, individual health insurance is another way to get coverage if you are not eligible for any of these plans.
Individual plans provide benefits similar to most employer plans. Depending on their income, individuals and families may pay even less for individual health coverage than for coverage through an employer.
Individual health insurance is available through federal and state Affordable Care Act (ACA) exchanges, as well as directly from insurance companies. If you are eligible for a plan here, you cannot be denied coverage. Depending on your income, you may also be eligible for aca plan subsidies.
how to get individual health insurance?
healthcare.gov has comparison tools, cost calculators, and educational resources to help you select the right plan for you and your family. The website can also help you estimate any premium subsidies you may be eligible for. healthcare.gov, as well as state websites, also have customer service representatives if you need help with the process.
If you live in one of the 17 states with your own exchange, you would use the state’s website to sign up. those states include:
- district of columbia
- new jersey
- new mexico
- new york
- rhode island
For all other states, use the federal government’s health insurance exchange healthcare.gov to enroll.
Not all insurers sell plans through the government-run health insurance marketplace. You can find more individual and family options by shopping directly through health insurance companies that offer plans outside of the exchanges. if you decide to shop outside the exchanges, remember that those plans are not eligible for subsidies.
Now, let’s take a look at when you can buy individual health insurance and the types of plans and other options.
when to buy an individual health plan
You can buy or make changes to individual health insurance during the open enrollment period. open enrollment for most states is from nov. 1 to Jan 15. States with their own exchanges often offer expanded open enrollment.
States with slightly different open enrollment periods include California, the District of Columbia, Idaho, Maryland, New Jersey and New York, and Rhode Island.
The only other time you can get individual health insurance coverage is if you have a qualifying event that starts a special enrollment period. these events may have caused you to lose your health insurance coverage. the special enrollment registration period lasts 60 days.
events that qualify for special entries include:
- getting married
- having a baby, adopting a child, or placing a child for adoption or foster care
- becoming a U.S. citizen citizen
- released from incarceration
- lost other health coverage in the last 60 days due to job loss, divorce, expiration of bills, or expiration of parent’s plan
- losing eligibility for medicaid or the children’s health insurance program (chip)
- change in income or household status that affects eligibility for premium tax credits or health insurance subsidies shared costs
- gain status as a member of an Indian tribe
The open registration of the market here is usually from Nov. 1 to Jan 15 in most states, but starting in 2022, low-income Americans will be more likely to get a plan from the Marketplace.
People with incomes up to 150% of the federal poverty level ($19,320 for a single person, $32,940 for a family of three) will be eligible for a special enrollment period each month. The Centers for Medicare and Medicaid Services estimate that approximately one-third of Marketplace plan members will qualify.
When do I need individual health insurance?
If you are not eligible for employer-sponsored health insurance, medicare, medicaid, veterans benefits, or any other government program, you must purchase individual health insurance.
You can buy individual health insurance through the aca marketplace, as well as non-aca policies through brokers and directly with insurance companies.
what do individual health plans cover?
aca marketplace individual health insurance plans offer comprehensive coverage. Marketplace plans here have to offer you coverage regardless of your health history. You qualify for individual health insurance even if you’re pregnant or have a long-term condition like diabetes or a serious illness like cancer. aca marketplace health plans cannot limit the amount of benefits you receive and limit the out-of-pocket costs you have to pay in a year.
In addition, all individual health plans on the aca marketplace must cover a standard set of 10 essential health benefits:
- Outpatient care, including doctor visits
- Emergency room visits
- Pregnancy and maternity care
- mental health and substance abuse treatment
- prescription drugs
- services and devices for recovery after an injury or due to a disability or chronic condition
- lab tests
- preventive services, including health exams, immunizations, and birth control. You pay nothing out of pocket for preventive care when you see health care providers in your plan’s network.
- Pediatric services, including children’s dental and vision care.
Plans that do not comply with ACA are available directly from insurance companies. They are usually less expensive, have limited benefits, and may deny coverage based on your health history.
how to choose individual health plans
There are different types of individual health plans. Plans on the ACA market are divided into four metal tiers for easy comparison. Tiers are based on the percentage of medical costs paid by plans and what you pay out-of-pocket. out-of-pocket expenses include deductibles, copays, and coinsurance.
Percentages are estimates based on the amount of health care the average person would use in a year. Platinum plans, which pay 90% of health care costs, are more expensive than Silver plans, which pay 70% of health care costs. not all providers accept all plans.
how much does it cost to buy health insurance on your own
Generally, the less you pay out-of-pocket for deductible, copays, and coinsurance, the more you spend on premiums. platinum plans charge higher premiums than the other three plans, but have lower deductibles. meanwhile, bronze has the lowest premiums but the highest out-of-pocket cost.
When deciding on the level, consider the medical services you used in the last year and what you expect in the next year. healthcare.gov, as well as individual state websites, have calculators to help you.
according to kff the kaiser family foundation. the average premiums for the bronze, silver and gold plans are:
bronze and silver are the most popular plans, with 32% of policyholders having silver plans and 56% having bronze plans. only 10% have gold plans and 1% have platinum plans.
what is the cheapest health insurance?
The cheapest premiums on the market here are the bronze plans. If you are eligible for subsidies, your premium cost for the Silver and Bronze plans may be similar. healthcare.gov and state websites have calculators to help you estimate your subsidies and total cost.
Plans that don’t comply may be less expensive, but benefits are limited. be sure to compare them to the plans here before making a decision.
individual health insurance subsidies
People who buy an individual health plan through the ACA exchanges may be eligible for subsidies that lower the cost of premiums.
the aca allows tax credits and grants. only people with household income below 400% of the federal poverty level are eligible for subsidies.
The 2021 US bailout increased grants as part of pandemic relief through 2022. However, the increased grant will expire unless Congress acts to extend it. When you search for a plan through the ACA exchanges, the site provides cost estimates that include allowances.
Reminder: People with an individual health plan outside of the exchanges are not eligible for subsidies.
other options for people looking for health insurance
individual health insurance is an option, but there are other ways besides an employer plan for a person to get coverage:
- Short-term plans: These plans do not offer the same benefits as a regular health insurance plan. insurers are not required to provide full benefits. maternity, prescription drugs and mental health are not covered by most short-term health plans. instead, you pay for that care yourself. short-term plans are not intended as a long-term health insurance solution. you can only have them for one year and you can request two extensions. These plans are low cost, but have limited benefits. Also, some states don’t allow short-term plans, while others restrict them to shorter terms.
- Medicaid –– Medicaid is available to qualifying people. Thirty-nine states expanded Medicaid, allowing people up to 138% of the federal poverty level to be eligible for Medicaid. that level is $17,609 for a single person, $23,791 for a family of two, and $36,156 for a family of four. Medicaid plan costs depend on your income, but you’ll pay less for Medicaid than an employer or individual plan if you qualify. medicaid offers comprehensive health insurance despite lower costs.
- catastrophic health plans: if you are under 30 or meet income requirements, you may qualify for a catastrophic health plan. These plans offer lower premiums but come with much higher deductibles and out-of-pocket costs than standard health insurance plans. The idea behind catastrophic plans is to cover people to avoid financial ruin if they have emergency health care needs. Unlike short-term health plans, which don’t cover many services, catastrophic plans offer the same level of coverage as standard ACA plans.
what to consider when buying individual health insurance
When shopping for an individual health insurance plan, you should consider your health care needs and your budget.
here are some questions to consider:
how much flexibility do you want in your plan?
When choosing an individual health plan, you want to consider the type of benefit design. Health maintenance organization (HMO) plans are the most common plan design in the individual market.
hmos include restricted provider networks. hmo members can only see doctors and receive care at facilities in those networks. You also need a referral from a primary care provider to see a specialist.
exclusive provider organization (epo) plans don’t let you get care out of network, but you also don’t need a referral to see a specialist.
Preferred Provider Organization (PPO) plans are more flexible. You can see doctors both in and out of network. you do not have to get referrals to see specialists. however, ppos have much higher premiums than hmos, so you pay more for that flexibility.
Discover the differences between hmos, ppos and other types of health plans.
Are your providers in the network?
Check your health plan’s network to make sure you have a good selection of hospitals, doctors, and specialists. look for your providers in the plan’s network.
This is especially true if you get an hmo. hmos has a restricted network and will not pay for care you receive outside of the network.
If you get a ppo, you may be able to get care outside of the network, but it may cost more.
what does private health insurance cover?
Check to see if the prescription drugs you take are included in the plan’s list of covered drugs. compare other benefits. some plans may go beyond the coverage required by law.
what is the reputation of insurance companies?
You’ll also want to look at consumer reviews and the company’s financial health. You can review the best health insurance companies on insure.com for customer satisfaction ratings and best company financial strength ratings a.m..
Making a smart individual health insurance choice takes time and effort, but the work you do now will pay off later when you and your family need care.
frequently asked questions about individual health insurance
– les masterson contributed to this report.
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