Health insurance plans are available both through private insurance companies and the government Health Insurance Marketplace. Individual health insurance plans are for people who don’t have access to coverage through a job or a government program. Family health insurance plans cover more than one person in a household under the same plan.
How to Get Health Insurance Coverage
Most people get health coverage in one of a few ways. You may have a group plan through your job or your spouse or partner’s job, or you can stay on a parent’s plan until you turn 26. You can buy a plan on your own directly from a health insurance company or through the Health Insurance Marketplace. Government programs such as Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and coverage through the Veterans Health Administration or TRICARE also provide coverage for people who qualify. If you leave a job, you may be able to keep your former employer’s coverage for a limited time under COBRA, though you usually pay the full premium yourself.
Types of Health Insurance Plans
When choosing a health insurance plan, you’ll need to decide how you want to access care. Most plans fall into four types.
HMO (Health Maintenance Organization)
An HMO usually limits coverage to doctors and hospitals in its network, except in emergencies. You typically choose a primary care doctor and need a referral to see a specialist. HMOs often have lower premiums in exchange for less flexibility.
PPO (Preferred Provider Organization)
A PPO lets you see doctors in or out of its network without a referral. You pay less when you stay in network, and out-of-network care costs more. PPOs usually have higher premiums because of that flexibility.
EPO (Exclusive Provider Organization)
An EPO covers care only from doctors and hospitals in its network, except in emergencies, but usually doesn’t require referrals to see specialists.
POS (Point-of-Service)
A POS plan blends HMO and PPO features. You usually need a referral from your primary care doctor to see a specialist, and you can go out of network at a higher cost.
Understanding Health Insurance Costs
Your premium is the amount you pay every month to keep your coverage, whether or not you use it. When you get care, you may also pay a deductible, which is the amount you pay for covered services before your plan starts to pay. After that, you usually share costs through copayments, which are flat fees for things like doctor visits, and coinsurance, which is a percentage of the bill.
Every Marketplace plan also has an out-of-pocket maximum. Once your deductibles, copayments, and coinsurance for covered in-network care reach that limit in a plan year, the plan pays 100% of covered services for the rest of the year. Plans with lower premiums usually have higher deductibles and out-of-pocket costs, so the right choice depends on how often you expect to use care.
There are many things to consider when purchasing health insurance. Make sure you do your research and ask questions before you decide which health plan is right for you, or talk with a licensed broker who can compare plans for you at no cost.
Individual and Family Health Insurance
The Affordable Care Act (ACA), passed in 2010, reshaped the individual health insurance market. Insurance companies can’t turn you down or charge you more because of a pre-existing condition, and every Marketplace plan must cover a core set of essential health benefits, including doctor visits, hospital care, prescriptions, maternity care, mental health care, and preventive services.
Marketplace plans are grouped into metal levels: Bronze, Silver, Gold, and Platinum. Bronze plans have the lowest premiums and the highest costs when you get care, while Platinum plans have the highest premiums and the lowest costs when you get care. Depending on your household income, you may qualify for a premium tax credit that lowers your monthly premium on a Marketplace plan.
The ACA originally included a federal tax penalty for going without coverage, but that penalty has been $0 since 2019. A few states, including California, Massachusetts, New Jersey, Rhode Island, and Washington, D.C., have their own coverage requirements. Learn more on our individual and family health insurance page.
What Health Insurance Covers
Every ACA-compliant individual and family plan must cover ten categories of essential health benefits: outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services and devices, lab services, preventive and wellness care, and pediatric services, including dental and vision care for children.
Many preventive services, such as annual checkups, certain screenings, and recommended vaccines, are covered at no cost to you when you use an in-network provider, even before you meet your deductible. Adult dental and vision care usually aren’t included, but you can add separate dental and vision coverage.
How to Choose the Right Health Plan
The plan with the lowest premium isn’t always the least expensive once you use it. Start by checking whether your doctors, specialists, and preferred hospitals are in the plan’s network, and whether your prescriptions are on its drug list and at what cost. Then compare the deductible and out-of-pocket maximum with how often you expect to need care.
If you rarely see a doctor, a plan with a lower premium and a higher deductible may make sense. If you manage an ongoing condition, take regular prescriptions, or are planning a pregnancy, a plan with a higher premium but lower deductible and copays can cost less over the full year.
High-Deductible Plans and Health Savings Accounts
Some plans qualify as high-deductible health plans (HDHPs) that can be paired with a health savings account (HSA). An HSA lets you set aside pre-tax money for medical costs, the balance rolls over from year to year, and the account stays with you if you change plans or jobs. The IRS sets the yearly contribution limits.
When You Can Enroll
You can buy an individual or family Marketplace plan during the annual Open Enrollment Period. On HealthCare.gov, open enrollment runs from November 1 to January 15 in most states, and states that run their own exchanges may set different dates. Outside open enrollment, you generally need a qualifying life event, such as losing other coverage, getting married, having a baby, or moving, to enroll during a Special Enrollment Period. You usually have 60 days after the event to sign up.
If you need coverage between plans, short-term health insurance may be an option in some states, though it doesn’t have to follow ACA rules. Small business owners can also look at group health insurance for their employees.
Government Health Insurance Programs
Several government programs provide health coverage for people who qualify. Medicare covers people 65 or older and some younger people with disabilities. Medicaid covers people with limited income and resources, and the Children’s Health Insurance Program (CHIP) covers children in families who earn too much for Medicaid but can’t afford private coverage. The Veterans Health Administration and TRICARE serve veterans, service members, and their families, and some states offer their own health insurance programs.
Why Work With a Health Insurance Broker
A licensed health insurance broker can compare plans from multiple insurance companies side by side, check your doctors and prescriptions against each plan, and explain the trade-offs in plain language. Plan prices are the same whether you buy directly from an insurance company, through the Marketplace, or through a broker, so working with a broker doesn’t add to your premium.
iHealthBrokers helps individuals, families, small businesses, and people approaching Medicare find coverage that fits their needs and budget, and we stay available after you enroll if questions come up during the year. Get a free quote or contact us to talk with a licensed broker.
