How to Buy An Individual Health Insurance Plan
Most Americans get health insurance through their employer. However, individual health insurance is another way to get coverage if you’re not eligible for an employer-sponsored plan or if your company’s plan is too expensive or limited.
Individual plans provide similar benefits as most employer plans. Depending on your income, you may pay even less for an individual health insurance plan than one through an employer.
Individual health plans are available through the Affordable Care Act (ACA) exchanges and outside the exchanges directly through insurance companies. You can’t get denied for an ACA plan. The health law requires that insurers cover anyone who applies.
Now, let’s take a look at when and how you can buy individual health insurance and the types of plans and other options.
When to buy an individual health plan
You can purchase or make changes to individual health insurance during the open enrollment period. Open enrollment for most states is from Nov. 1 to Dec. 15 each year. States with their own exchanges usually offer expanded open enrollment.
For instance, states with expanded open enrollment for 2021 plans are:
- California – Nov. 1, 2020 to Jan. 31, 2021
- Colorado – Nov. 1, 2020 to Jan. 15, 2021
- D.C. – Nov. 1, 2020 to Jan. 31, 2021
- Massachusetts – Nov. 1, 2020 to Jan. 23, 2021
- Minnesota – Nov. 1 to Dec. 22, 2021
- Nevada – Nov. 1, 2020 to Jan. 15, 2021
- New Jersey -- Nov. 1, 2020 to Jan. 31, 2021
- New York – Nov. 1, 2020 to Jan. 31, 2021
Special enrollment qualifying events include:
- Getting married
- Having a baby, adopting a child or placing a child for adoption or foster care
- Moving
- Becoming a U.S. citizen
- Leaving incarceration
- Losing other health coverage due to job loss, divorce, COBRA expiration or aging off a parent’s plan
- Losing eligibility for Medicaid or the Children’s Health Insurance Program (CHIP)
- People with a marketplace plan already may be eligible for a special enrollment period if there’s a change in income or household status that affects eligibility for premium tax credits or cost-sharing subsidies
- Gaining status as a member of an Indian tribe
What do individual health plans cover?
Before the ACA, individual health plans’ coverage varied widely. Insurers could deny your application for insurance or set exorbitant premiums if you had a health condition.
Now, insurers have to cover you regardless of your health history. You qualify for individual health insurance even if you're pregnant, have a long-term condition like diabetes or a serious illness, such as cancer.
Insurers also can't charge you exceedingly more because of medical conditions. Health plans additionally can't cap the amount of benefits you receive. They’re also limited on how much out-of-pocket costs you have to pay.
In addition, all individual health plans must cover a standard set of 10 essential health benefits:
- Outpatient care, including doctor’s visits
- Emergency room visits
- Hospitalization
- 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 screenings, immunizations and birth control. You pay nothing out of pocket for preventive care when you see health care providers in a health plan's network.
- Pediatric services, including dental and vision care for kids
Types of individual health plans
Individual health insurance plans don’t differ in terms of benefits. However, plans vary on costs, how they’re structured, which doctors accept them and which prescription drugs they cover.
Health plans in the ACA marketplace are divided into four metal categories to make comparing them easier. The categories are based on the percentage of health care costs the plans pay and the portion you pay out of pocket. Out-of-pocket costs include deductibles, co-payments and co-insurance.
The percentages are estimates based on the amount of medical care an average person would use in a year.
- Bronze - Plan pays 60% of your health care costs. You pay 40%.
- Silver - Plan pays 70% of your health care costs. You pay 30%.
- Gold - Plan pays 80% of your health care costs. You pay 20%.
- Platinum - Plan pays 90% of your health care costs. You pay 10%.
Generally, the less you pay out-of-pocket for the deductible, co-payments and co-insurance, the more you spend in premiums. So, in this case, Platinum plans charge higher premiums than the other three plans, but you won't pay as much if you need healthcare services. Bronze, meanwhile, has the lowest premiums but the highest out-of-pocket costs.
When deciding on the level, consider the healthcare services you used over the past year and what you expect for next year. For instance, if you plan on starting a family, consider how much out-of-pocket costs you'll have to pay if you go with a Bronze plan.
eHealth reported the average monthly premium by metal level:
- Bronze -- $448
- Silver -- $483
- Gold -- $569
- Platinum -- $732
Bronze and Silver are the most popular plans -- 42% have Bronze plans and 34% have Silver plans. Only 14% have Gold plans and 2% have Platinum plans.
When choosing an individual health plan, you’ll also want to consider the type of plan design. Health maintenance organization (HMO) plans are the most common plan design in the individual market. eHealth estimated that 49% of individual plans are HMOs.
HMOs include restricted provider networks. HMO members can only see doctors and get care from facilities in those networks. Also, you need a primary care provider referral to see a specialist.
Exclusive provider organization (EPO) plans make up one-third of individual market plans. These plans don't allow you to get care outside of your network, but you also don't need a referral to see a specialist.
Preferred provider organization (PPO) plans are the most common type of plan in the employer-sponsored health insurance market. Forty-seven percent of employer-sponsored health plan members have a PPO. However, only 16% of individual health insurance plans are PPOs.
PPOs are more flexible. You’re able to see doctors both in your network and outside the network. You don’t have to get referrals to see specialists. However, PPOs have much higher premiums than HMOs, so you pay more for that flexibility.
Find out the differences between HMOs, PPOs and other types of health plans.
Individual health insurance subsidies
People who buy an individual health plan through the ACA exchanges may be eligible for subsidies that reduce the cost of premiums.
The ACA allows tax credits and subsidies for anyone with an exchange plan whose income is below 400% of the federal poverty level.
For 2021 health plans, the 400% threshold is $51,040 for a single person. Here are more examples:
- Household of 2 -- income less than $68,960
- Household of 3 -- income less than $86,880
- Household of 4 -- income less than $104,800
- Household of 5 -- income less than $122,720
When you search for a plan through the exchanges, the site will provide cost estimates for plans with subsidies in mind.
Reminder: People with an individual health plan outside of the exchanges aren’t eligible for subsidies.
Other options for people looking for health coverage
Individual health insurance is an option, but there are other ways beyond an employer plan for a person to get coverage:
● Short-term plans -- These plans don’t offer the same benefits as a normal health insurance plan. Insurers aren’t required to provide comprehensive benefits. Most short-term health plans don’t cover maternity, prescription drugs and mental health. Instead, you’ll have to pay for that care yourself. Short-term plans aren’t meant as a long-term health insurance solution. You can only have them for one year and can request two extensions. These plans are low-cost, but they have limited benefits. Also, handful of states don't allow short-term plans, while others restrict them to shorter time frames.
● Medicaid -- Medicaid is available to people who qualify. Thirty-eight states expanded Medicaid, which allows people who make up to 138% of the federal poverty level eligible for Medicaid. That level is $17,609 for a single person, $23,791 for two people and $36,156 for a family of four. The costs of Medicaid plans 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 the lower costs.
● Catastrophic health plans -- If you’re under 30 or meet income requirements, you could qualify for a catastrophic health plan. These plans offer lower premiums but come with much higher deductibles and out-of-pocket costs. The plans cover young and people with low-income who couldn’t afford a regular health insurance plan. The idea behind catastrophic plans is to give them coverage to prevent 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 a standard ACA plan.
How to buy individual health insurance
The health insurance marketplace is the ACA exchanges website, making it simple for people to compare individual health plans. You simply enter in your information, including your income, and the site provides your health plan options, including estimated costs and factors in subsidies. That’s the place to start when looking for your options.
Not all insurers sell plans through the government-run marketplace. You can find more options by shopping directly through health insurance companies that offer plans outside of the exchanges. That will take more work to compare the insurers, but you may also find a plan that better fits your needs out of the exchanges.
When shopping for an individual health insurance plan, you’ll want to consider your health care needs and your budget.
Who’s in the network?
Check the health plan's network to make sure it has 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 have a restricted network and won’t pay for the care you receive outside of the network.
If you get a PPO, you’ll likely be able to get out-of-network care, but it can come at a higher price tag.
Find out more about the differences between health plans.
What is covered?
Check to see if the prescription drugs you take are included in the plan's list of covered medications. Compare other benefits. Some plans may go above and beyond coverage mandated by law.
What are the insurance companies’ reputations?
You’ll also want to check out the company’s consumer reviews and financial standing. You can review Insure.com’s Best Health Insurance Companies for customer satisfaction ratings and company A.M. Best Financial Strength Ratings.
Making a smart individual health insurance choice requires time and effort, but the homework you do now will pay off later when you and your family need care.
