Insurance

Health Insurance Plans for Individuals and Families

How to Get Health Insurance

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:

 

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.

 

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.

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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.

 

STATE HEALTHCARE MARKETPLACE DEPARTMENT OF INSURANCE
Alabama Healthcare.gov(800) 318-2596 Alabama Department of Insurance(334) 241-4141
Alaska Healthcare.gov(800) 318-2596 Alaska Division of Insurance(907) 269-7900
Arizona Healthcare.gov(800) 318-2596 Arizona Department of Insurance Consumer Affairs Division(602) 364-2499
Arkansas Healthcare.gov(800) 318-2596 Arkansas Insurance Department(501) 371-2640
California Covered California(800) 300-1506 California Department of Managed Healthcare(888) 466-2219
Colorado Connect for Health Colorado(855) 752-6749 Colorado Division of Insurance(303) 894-7499
Connecticut Access Health CT(855) 805-4325 Connecticut Office of the Healthcare Advocate(866) 466-4446
Delaware Healthcare.gov(800) 318-2596 Delaware Department of Insurance(302) 674-7300
District of Columbia DC Health Link(855) 532-5465 Department of Insurance, Securities and Banking(202) 727-8000
Florida Healthcare.gov(800) 318-2596 Florida Division of Consumer Services(877) 693-5236
Georgia Healthcare.gov(800) 318-2596 Georgia Office of Insurance and Safety Fire Commissioner, Consumer Services Division(404) 656-2070
Hawaii HealthCare.gov(808) 260-9011 Hawaii Department of Commerce & Consumer Affairs(808) 586-2790
Idaho Your Health Idaho(855) 944-3246 Idaho Department of Insurance(800) 721-3272
Illinois Healthcare.gov(800) 318-2596 Illinois Department of Insurance(217) 782-4515
Indiana Healthcare.gov(800) 318-2596 Indiana Department of Insurance Consumer Services(317) 232-2395
Iowa Healthcare.gov(515) 281-5705 Iowa Insurance Division(515) 654-6600
Kansas Healthcare.gov(800) 318-2596 Kansas Insurance Department(785) 296-3071
Kentucky Healthcare.gov(800) 318-2596 Kentucky Department of Insurance Consumer Protection Division(502) 564-3630
Louisiana Healthcare.gov(800) 318-2596 Louisiana Department of Insurance, Office of Consumer Services(225) 342-5900
Maine Healthcare.gov(800) 318-2596 Maine Department of Professional and Financial Regulation(207) 624-8475
Maryland Maryland Health Connection(855) 642-8572 Maryland Health Education and Advocacy Unit(410) 528-1840
Massachusetts Massachusetts HealthConnector(877) 623-6765 Massachusetts Office of Consumer Affairs and Business Regulation, Division of Insurance(617) 521-7794
Michigan Healthcare.gov(800) 318-2596 Michigan Department of Insurance and Financial Services(877) 999-6442
Minnesota MNsure(855) 366-7873 Minnesota Department of Commerce Insurance Division(651) 539-1500
Mississippi Healthcare.gov(800) 318-2596 Mississippi Insurance Department(800) 562-2957
Missouri Healthcare.gov(800) 318-2596 Missouri Department of Insurance(800) 726-7390
Montana Healthcare.gov(800) 318-2596 Office of the Montana State Auditor, Commissioner of Securities and Insurance (CSI)(800) 332-6148
Nebraska Healthcare.gov(800) 318-2596 Nebraska Department of Insurance(877) 564-7323
Nevada Navada Health Link(800) 547-2927 Nevada Division of Insurance(775) 687-0700
New Hampshire Healthcare.gov(800) 318-2596 New Hampshire Insurance Department(603) 271-2261
New Jersey Healthcare.gov(800) 318-2596 New Jersey Department of Banking and Insurance(800) 446-7467
New Mexico New Mexico Health Insurance Exchange(833) 862-3935 New Mexico Office of Superintendent of Insurance(855) 427-5674
New York NY State of Health(855) 355-5777 New York State Department of Financial Services(800) 342-3736
North Carolina Healthcare.gov(800) 318-2596 North Carolina Department of Insurance(855) 408-1212
North Dakota Healthcare.gov(800) 318-2596 North Dakota Insurance Department(800) 247-0560
Ohio Healthcare.gov(800) 318-2596 Ohio Department of Insurance(614) 466-2000
Oklahoma Healthcare.gov(800) 318-2596 Oklahoma Insurance Department(800) 522-0071
Oregon Healthcare.gov(800) 318-2596 Oregon Division of Financial Regulation(888) 877-4894
Pennsylvania Pennie(844) 844-8040 Pennsylvania Insurance Department(877) 881-6388
Rhode Island HealthSource RI(855) 840-4774 Office of the Health Insurance Commissioner(401) 270-0101.
South Carolina Healthcare.gov(800) 318-2596 South Carolina Department of Insurance(803) 737-6180
South Dakota Healthcare.gov(800) 318-2596 South Dakota Division of Insurance(605) 773-3563
Tennessee Healthcare.gov(800) 318-2596 Tennessee Department of Commerce and Insurance(800) 342-4029
Texas Healthcare.gov(800) 318-2596 Texas Department of Insurance(800) 252-3439
Utah Healthcare.gov(800) 318-2596 Utah Insurance Department(801) 538-3077
Vermont Vermont Health Connect(855) 899-9600 Vermont Insurance Division Department of Financial Regulation(800) 964-1784
Virginia Healthcare.gov(800) 318-2596 Virginia State Corporation Commission Bureau of Insurance(804) 371-9741
Washington Washington Health Plan Finder(855) 923-4633 Washington State Office of the Insurance Commissioner(800) 562-6900
West Virginia Healthcare.gov(800) 318-2596 West Virginia Offices of the Insurance Commissioner(888) 879-9842
Wisconsin Healthcare.gov(800) 318-2596 Wisconsin Office of the Commissioner of Insurance(800) 236-8517
Wyoming Healthcare.gov(800) 318-2596 Wyoming Department of Insurance(307) 777-7401
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