July 23, 2024
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Insurance

Health Insurance Plans for Individuals and Families in US

How to Get Health Insurance

 

More than half of all Americans under age 65 get their insurance through their employer, according to the Commonwealth Fund. The rest get it through Medicaid or the individual insurance market (or are uninsured). Those ages 65 and older automatically qualify for Medicare.

For those who have lost their employee-sponsored insurance, or never had it, there are five options, which depend on your income, which state you live in and whether you had coverage recently.

  1. Continue your employer’s coverage through the Consolidated Omnibus Budget Reconciliation Act of 1985, or COBRA.
  2. Sign up for coverage through your state’s insurance marketplace or Healthcare.gov.
  3. Join your spouse’s plan.
  4. Sign up for Medicaid if you meet income requirements.
  5. Sign up for Medicare if you’re 65 or older.

COBRA is the easiest but most expensive option for those who have lost employer coverage. Employers typically pay about 75% of the premiums for their employees, with the employee responsible for the rest. The average employee paid $1,242 for single coverage in 2019. But you’d have to pay the full cost on COBRA, which averaged $7,188 for the year. The contribution for family coverage averaged $6,015 in 2019, but the full cost of coverage averaged $20,576.

You can find individual health insurance policies and pricing at your state’s marketplace or HealthCare.gov. You may qualify for a special enrollment period if you lose your job and coverage – in which case you have up to 60 days after you lose your employer’s coverage to buy a policy.

No matter what state you live in, you can enroll in affordable, quality health coverage as mandated by the Affordable Care Act. You can find links to your state’s marketplace at Healthcare.gov. Residents of states without an individual marketplace purchase their insurance directly through Healthcare.gov.

hen Is Open Enrollment for Health Insurance?

 

To sign up for insurance through your state’s marketplace or Healhtcare.gov, you usually have to wait until the open enrollment period, which generally runs from Nov. 1 to Dec. 15 every year. That is also the time when you can change your employer-sponsored coverage if you wish.

You also can enroll in or change your marketplace plan if you have a life event that qualifies you for a Special Enrollment Period. According to Healthcare.gov, you may qualify for a Special Enrollment Period if you or anyone in your household in the past 60 days:

  • Got married. Pick a plan by the last day of the month and your coverage can start the first day of the next month.
  • Had a baby, adopted a child or placed a child for foster care. Your coverage can start the day of the event – even if you enroll in the plan up to 60 days afterward.
  • Got divorced or legally separated and lost health insurance. Note: Divorce or legal separation without losing coverage doesn’t qualify you for a Special Enrollment Period.
  • Died. You’ll be eligible for a Special Enrollment Period if someone on your Marketplace plan dies and as a result you’re no longer eligible for your current health plan.
  • You or anyone in your household lost qualifying health coverage in the past 60 days or expects to lose coverage in the next 60 days.
  • You lost coverage more than 60 days ago, but since Jan. 1, 2020, and didn’t enroll sooner because you were impacted by the COVID-19 emergency.

 

Household moves that qualify you for a Special Enrollment Period:

  • Moving to a new home in a new ZIP code or county.
  • Moving to the U.S. from a foreign country or United States territory.
  • If you’re a student, moving to or from the place you attend school.
  • If you’re a seasonal worker, moving to or from the place you both live and work.
  • Moving to or from a shelter or other transitional housing.

 

Health insurance is basically a contract that requires your health insurance company to pay some or all of your health care costs in exchange for a monthly payment called a premium. Each plan offers different types and amounts of coverage, but all typically cover doctor visits (for certain doctors within that plan), hospital stays, prescription drugs and some other services. More comprehensive plans may cover mental health care, dental care, vision care, physical and occupational therapy, behavioral health care and more.

In addition to the premium, most plans require you to pay other costs for your health care. These may include:

  • A deductible. This is an amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
  • Copayments. This is a set fee you pay for a covered health care service after you’ve paid your deductible – typically $5 to $25 per service.
  • Coinsurance. This is a percentage of costs of a covered health care service you pay after you’ve paid your deductible.

With all these variables, it’s very important to look closely at the details of each plan you consider to be sure it covers you for the care and services you’re most likely to require and includes the doctors and hospitals you want treating you.

There are different types of health insurance plans designed to meet different needs. Some types restrict your choices of doctors or require you to use the plan’s network of doctors, hospitals, pharmacies and other medical service providers, or pay more out-of-pocket for providers outside the plan’s network.

Understand Health Maintenance Organizations (HMOs)

 

An HMO plan usually covers care only from doctors who work for or contract with the HMO. It usually won’t cover out-of-network care except in an emergency. Some HMOs require that you live or work in its service area to be eligible for coverage. HMOs often stress integrated health care, with a focus on prevention and wellness.

Understand Exclusive Provider Organizations (EPOs)

 

An EPO is a managed care plan that only covers services rendered by the doctors, specialists or hospitals in the plan’s network. The only exception is in the case of an emergency.

Understand Point-of-Service (POS) Plans

 

POS plans have lower out-of-pocket fees if you use doctors, hospitals and other health care providers that belong to the plan’s network. POS plans also require a referral from your primary care doctor before you can see a specialist.

Understand Preferred Provider Organizations (PPOs)

 

PPO plans contract with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the PPO network. You can use doctors, hospitals, and providers outside of the network, but you pay an additional cost.

hat’s the Difference Between Government and Private Insurance Companies?

 

Health care coverage is offered by both public and private providers. The government provides public health care through two national health care systems, Medicare and Medicaid. Private health insurance is offered through for-profit insurance companies. The Affordable Care Act places rules and regulations on for-profit companies who sell their products through marketplace exchanges overseen by each state.

Anyone who reaches age 65 automatically qualifies for Medicare, and this becomes their primary source of health insurance. Secondary insurance, obtained through an employer, spouse or through the marketplace, can cover costs not paid for by Medicare. This is known as Medigap insurance.

Medicaid is primarily for low-income and disabled individuals, and is based on income. The Children’s Health Insurance Program (CHIP), a subset of Medicaid, offers subsidized low- or no-cost health insurance for children.

 

According to eHealth, the average cost for health insurance nationally in 2020 was $456 for an individual and $1,152 for a family per month. However, costs vary widely among the large selection of health plans and according to state regulations.

Under the ACA, you may qualify for a subsidy to help pay your premiums, depending on the number of people in your family and your income for the year. These subsidies can substantially lower monthly premiums. (See “Affordable Health Insurance,” below.)

Another option is to sign up for personalized medical services, often known as concierge medicine or direct primary care. You pay a monthly or annual fee to access care directly from your physician. According to the American Academy of Family Physicians, these arrangements have average costs ranging from $77 to $183 a month. Some practices still bill your insurance on top of that monthly fee. Others do not accept other insurance coverage, and often charge higher fees as a result.

ffordable Health Insurance

 

The Affordable Care  is a comprehensive health care reform law enacted in March 2010. It is sometimes known as the ACA, PPACA or “Obamacare.” According to the Centers for Medicare and Medicaid Services, the law has three primary goals:

  • Make affordable health insurance available to more people. The law provides consumers with subsidies, in the form of premium tax credits, that lower costs for households with incomes between 100% and 400% of the federal poverty level. That can go up to about $50,000 a year for individuals and more than $100,000 a year for a family of four.
  • Expand the Medicaid program to cover all adults with income below 138% of the federal poverty level. However, many states have chosen not to expand their Medicaid programs.
  • Support innovative medical care delivery methods designed to lower the costs of health care generally.

Open enrollment for ACA programs generally runs from Nov. 1 to Dec. 15. You also can enroll in a plan or change your plan if you have a life event that qualifies you for a Special Enrollment Period.

There are also cheaper health insurance plans available, known as short-term plans. These plans are not required to comply with ACA regulations and offer far less comprehensive coverage. Most insurance experts recommend avoiding short-term plans if at all possible, as the money you save in premiums will be dwarfed by the costs of care you are responsible for should you need it.

 

A group health insurance plan provides coverage for a group of individuals, usually the employees of a company or members of an association. Costs are generally lower for group plans because the risk is spread among more policyholders.

Health coverage, whether it’s offered by your employer or through the health insurance marketplace, is available as an individual (single person) or family plan.

Health Insurance Plans for Individuals. Individual health insurance policies are available under the ACA for people who don’t have or have lost job-based coverage. Individual health insurance policies are regulated under state law.

Health Insurance Plans for Families. These plans cover two or more people, including dependent children. Under the ACA, dependent children may remain on their family plan until age 26. This applies to both employer plans and individual market plans.

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