Are you contemplating purchasing individual health insurance but are unsure what these policies entail? How do they function? Should you think about buying one? This article discusses the answers to all of these essential issues, as well as others.
Health insurance assists in covering the costs of a person’s medical and surgical bills. There are several different sorts of plans, each with its own set of benefits and treatment options. A person in the United States is currently required to obtain health insurance coverage. Anyone who does not have insurance may be subject to a fine.
There are a plethora of insurance options available, particularly for people. The majority of these policies address a variety of demands and hazards. Your personal health plan might be the finest investment you’ve ever made. Ensure that you and your entire family are covered. Try to figure out what the best benefit is. It’s a sense of relief! What would you be prepared to pay for that?
According to the Kaiser Family Foundation, the number of individuals without health insurance declined by almost 20 million after the Affordable Care Act was enacted in 2010, reaching its lowest level ever in 2016. (KFF). However, between 2016 and 2019, the number of individuals without health insurance increased by 2.2 million, from 26.7 million to 28.9 million.
Depending on the type of health insurance coverage you have, you pay out of pocket and get reimbursed, or pay the provider directly. Health insurance is commonly included in employer benefit packages in countries without universal healthcare coverage, such as the United States.
Table of Contents
- 1 What is individual health insurance?
- 2 Who needs individual health insurance?
- 3 What is covered in individual health insurance?
- 4 What is not covered in individual health insurance?
- 5 Difference between individual health insurance and employer-sponsored health insurance
- 6 How can I buy individual health insurance?
- 7 How much does individual health insurance cost?
- 8 Advantages of individual health insurance
- 9 Choosing the best individual health insurance plan
- 10 Choosing a Deductible
- 11 How can I get individual health insurance at less premium?
- 12 Conclusion
What is individual health insurance?
Unlike coverage obtained via an employer or a government-run program like Medicare, Medicaid, or CHIP, individual health insurance is coverage purchased on an individual or family basis.
People can obtain individual health insurance through a government exchange or marketplace (often referred to as ACA plans) or from commercial insurers due to the Affordable Care Act (ACA). You may only be able to get health insurance through a government exchange during specific periods of the year. In most cases, you may get health insurance from a private insurance provider at any time.
Individual health insurance alternatives can be better understood by looking at ACA policies. Metals are used to classify ACA health plans. More information on the metallic programs may be found here: Bronze, Silver, Gold, and Platinum.
Many people obtain health insurance through a group plan offered by their job or union, while others must purchase it independently. Even if you include family members on the plan, you get an individual plan when buying your health insurance. If this sounds like you, let eHealth show you all of your individual and family health insurance alternatives, and use our free quote comparison tool to choose a plan that suits your needs at an affordable price.
Hospitalizations, outpatient and preventative care, maternity and child services, lab testing, rehabilitation services, mental health treatment, and prescription medicines are all required to be covered by all ACA plans. Each insurer has complete control over how these and maybe other benefits are delivered. The metallic levels assist purchasers in determining what part of healthcare expenditures the plan will cover on average and what amount will be paid by the user.
Who needs individual health insurance?
Individual health insurance is for people who do not have access to the provider or government-run healthcare. Persons who work for a small firm that does not provide medical benefits, self-employed people, and people who retire before they are eligible for Medicare and must purchase their own health insurance until they reach the age of 65 fall into this category.
What is covered in individual health insurance?
Review your benefits to check which services are covered if you already have insurance and maintain it. It’s possible that your plan doesn’t cover all of the things that another plan does. Compare your plan to the ones available via the Health Insurance Marketplace. The Health Insurance Marketplace is a tool that allows you to compare and shop for health insurance coverage. The federal government is in charge of it.
Essential Health Benefits
Preventive care is usually covered by most insurance policies. This does not imply that they are unrestricted. Deductibles, copayments, and other out-of-pocket expenses may still be required.
Shots and various health checks are among the preventative services available. Preventive treatments are covered by your insurance if you purchase a plan via the Health Insurance Marketplace. It will also cover at least 10 of the Affordable Care Act’s core health benefits (ACA).
The following ten essential health benefits (EHBs) will be included in all private health insurance plans sold in federally facilitated marketplaces:
- Patient ambulatory services (outpatient care you get without being admitted to a hospital).
- Emergency services are available.
- Admission to a hospital (such as surgery).
- Maternity, neonatal care, and pregnancy (care before and after your baby is born).
- Services for mental health and substance abuse disorders, as well as behavioral health care (this includes counseling and psychotherapy).
- Medications on prescription.
- Services and gadgets for rehabilitative and habilitative purposes (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills).
- Services in the laboratory.
- Services for prevention and wellness, as well as chronic illness treatment.
- Oral and eye care for children (adult dental and vision treatment is not covered by EHBs).
Preventive services can identify the disease and assist in the prevention of sickness and other health issues. Your gender, age, medical history, and family history all influence the sorts of preventative care you require. Without requiring a copayment, all Health Insurance Marketplace plans must cover the following:
All adults should read this:
- One-time screening for abdominal aortic aneurysm (for men ages 66-75 who have smoked).
- Screening and therapy for alcoholism.
- Adults aged 50 to 59 years old would benefit from taking aspirin.
- Blood pressure measurements are taken.
- Adults with a higher risk of heart disease should have their cholesterol checked.
- Adults aged 50 to 75 years old should be screened for colorectal cancer.
- Screening for depression.
- Adults who are at a higher risk of tuberculosis should be screened.
- Adults aged 40 to 70 who are overweight should be screened for diabetes (type 2).
- Adults at risk of chronic illness get diet guidance.
- Adults aged 65 and up should be aware of the dangers of falling.
- Hepatitis B testing is recommended for persons who are at a higher risk.
- Hepatitis C testing is recommended for persons who are at a higher risk.
- HIV testing is a good idea.
- Vaccines for immunisation
- Adults aged 55 to 80 who are at elevated risk of lung cancer due to smoking should get their lungs screened.
- Obesity screening and counseling are both available.
- Counseling on preventing sexually transmitted infections for people who are at a higher risk.
- Preventive statin therapy for high-risk people aged 40 to 75 years.
- Syphilis testing is recommended for persons who are at a higher risk of contracting the disease.
- Screening for tobacco usage.
For women who are pregnant or may become pregnant:
- Screening for anemia.
- Breastfeeding is a complex process that requires a lot of help and advice.
- Supplements containing folic acid.
- Screening for gestational diabetes.
- All women who are at a higher risk for gonorrhea should be screened.
- Pregnant women should be screened for hepatitis B.
- Preventing and detecting preeclampsia.
- Screening for RH incompatibility.
- Screening for syphilis
- Tobacco intervention and counseling for pregnant women who use tobacco should be expanded.
- Screening for infections in the urinary tract or elsewhere.
Other preventative treatments for women that are covered include:
- For women who are at a higher risk of breast cancer, genetic testing is recommended.
- For women above the age of 40, mammography scans are recommended every 1 to 2 years.
- Chemoprevention counseling for breast cancer.
- Cervical cancer screening is a procedure that is used to detect cervical cancer. (This includes a Pap test every three years for women between the ages of 21 and 65.)
- Screening for chlamydia infection.
- Diabetic testing.
- Screening and counseling for domestic and interpersonal violence.
- Screening for gonorrhea.
- HIV testing and counseling are available.
- Women over the age of 60 should get their bones tested for osteoporosis.
- Follow-up testing for Rh incompatibility.
- Counseling for sexually transmitted illnesses.
- Screening for syphilis
- Screening and interventions for tobacco use.
- Screening for urinary incontinence.
- Women under the age of 65 are eligible for well-woman checkups.
What is not covered in individual health insurance?
Although each benefit plan is unique, based on the demands of the sponsor and state rules (each state has its own insurance commissioner), most health insurance plans do not cover certain treatments.
Many services that alter a person’s look, such as cosmetic surgery and other dermatological procedures, are sometimes not covered by standard insurance policies. Surprisingly, because people choose to undergo these treatments, there is a high level of pricing transparency. If a customer wants laser hair removal, they may phone any number of companies and get a pricing quotation right away.
Although health insurers are supposed to pay for all of the tests necessary to make an infertility diagnosis, these fees are frequently not covered by insurance.
This is, however, one of the therapy areas where states diverge.
For certain conditions, such as autoimmune diseases, prescription medications are evaluated and authorized. These medications are sometimes administered for conditions that aren’t stated on the “label.” The insurance provider may refuse to pay for these off-label usages in specific situations.
New technology in products or services
Covering these expenses can take a long time, especially if the technology does not provide a clear advantage in exchange for the higher expenditures. Medical firms must demonstrate that new medicine, product, or test delivers a meaningful benefit to the customer, which justifies the expense by lowering death or morbidity rates (basically, saving lives or reducing ill health). Other insurance plans often follow Medicare’s lead and wait for further data before integrating new technologies in covered services.
Difference between individual health insurance and employer-sponsored health insurance
The disparities between individual and employer-sponsored health care are substantially less important now that the Affordable Care Act has been implemented.
Individual health insurance was generally less expensive than group coverage in most states prior to 2014, while employers typically pay a significant percentage of group coverage premiums, giving consumers the impression that their coverage is much less expensive than it actually is.
Pre-2014, there was a hefty price disparity since individual policies were medically underwritten in virtually every state, making pre-existing conditions a barrier to coverage. Furthermore, the degree of coverage was generally lower than that of group plans. For example, before the Affordable Care Act mandated it, most group plans provided maternity care, although individual policies often did not.
All of that changed in 2014 when most of the Affordable Care Act’s provisions went into force. With the introduction of the Affordable Care Act’s essential health benefits, individual plans became more benefit-rich and guaranteed issues, meaning that eligibility is no longer based on medical history and applicants are no longer subjected to higher premiums or rejections due to pre-existing conditions. However, registration is now restricted to one yearly open enrollment period and special enrollment periods prompted by qualifying events.
As a result, full-price individual health insurance premiums are now nearly as costly as employer-sponsored coverage prices: In 2020, a single individual’s entire premium (pre-subsidy) for individual health insurance purchased through the marketplaces/exchanges was around $6,900 for the year, while an employer-sponsored plan’s average cost was $7,470.
However, there are some distinctions. Employer-sponsored plans, for example, are far more likely to be PPOs and extensive provider networks. In contrast, individual plans are much more likely to be HMOs or EPOs with relatively small networks and confined coverage regions. Even for plans offered by the same insurance company in the same location, this is frequently true, with separate networks for the insurer’s individual policies vs. their employer-sponsored plans.
Another significant distinction is that the typical deductibles for individual market plans are often higher. The average deductible on an employer-sponsored medical coverage plan in 2020 was $1,644, which was significantly higher than the deductibles for policies purchased via the marketplace/exchange in most states. In most locations, lower deductible choices are available, but customers who buy their own coverage are price sensitive, making the extremely comprehensive — but pricey — policies less popular overall.
How can I buy individual health insurance?
In every state, individual health insurance is offered through the exchange/marketplace. In 2021, the data says that 36 states use HealthCare.gov as its exchange platform, while DC and the remaining 14 states run their own (Covered California, MNsure, Connect for Health Colorado, etc.).
Excluding the District of Columbia, individual health insurance is also accessible outside of the marketplace (i.e., “off-exchange”) (in DC, individual health insurance can only be purchased through the market). However, if the plan is purchased through the marketplace, premium subsidies (premium tax credits) and cost-sharing reductions are also available.
Individual health insurance is only offered during the yearly open enrollment period or during a particular enrollment period prompted by a qualifying event in both circumstances — on-exchange and off-exchange. The yearly open enrollment period in most states runs from November 1 to December 15, with coverage beginning on January 1. However, most states that operate their own exchange systems have more extended enrollment periods, some extending well into January.
Plan availability and coverage options differ significantly from one region to the next. In some areas of the nation, there is only one insurer selling individual health insurance, while in others, there are multiple insurers and hundreds of healthcare plans to pick from.
You may get personal advice from an insurance broker in your region whether you want to buy your plan on-exchange or off-exchange. There are also navigators and enrollment counselors available to answer questions and give information and support with both on-exchange and Medicaid plan options.
How much does individual health insurance cost?
Individual health insurance premium costs vary substantially based on the applicant’s age, zip code, whether or not they smoke, and which health insurance carrier they pick. However, unlike plans issued in most states before 2014, premiums are not dependent on a person’s gender or medical history.
The average monthly cost for the more than 10.5 million persons who registered in effectuated individual health insurance coverage through the marketplaces in 2020 was $575. However, that is the full-price premium, and most individuals do not pay that: In 2020, 86 percent of marketplace registrants received premium tax credits (subsidies), averaging $491 per month. The federal government pays premium tax credits directly to health insurers, covering the vast majority of the typical premium.
In 2020, the average monthly full-price premium for employer-sponsored coverage (for a single employee) was around $623. On the other hand, employers paid an average of $519 per month of that expense, leaving the average employee with only $104 per month to pay out of pocket (payroll deducted, on a pre-tax basis).
Individual health insurance policies are often more expensive than short-term health insurance plans. Individual health insurance plans that comply with the Affordable Care Act (ACA) can be less costly than short-term plans for persons who qualify for premium tax credits.
Advantages of individual health insurance
Individual health insurance policies have several advantages. Take a look at some of the most significant benefits listed below:
Tailor-made for you
The most significant advantage of individual insurance is that you get to pick the one that best suits your needs. You may get health insurance that is tailored to your unique requirements. Group health insurance and family floater plans may not provide for this level of freedom.
If you are prone to accidents, for example, you can acquire health insurance that gives higher accidental coverage while lowering critical disease coverage (which you may not need to claim). Meanwhile, your sister’s health insurance might be changed to include maternity coverage.
Guaranteed coverage amount
When you get health insurance, you are given a specific policy sum insured to pay your medical expenses. This is true even if you purchase individual health insurance coverage in bulk for your entire family. Let’s look at an example to help you understand!
Harry, 25, purchased individual health insurance covers for himself, his mother, and his younger brother. Each person was insured for $20,000. As a result, when his mother was hospitalized for an extended time, she had a guaranteed coverage of $20,000.
Everyone is covered
Your family would not have to be concerned about a lack of coverage in the event that someone else became ill. Because the money insured is for a person rather than a family, this is the case. Even if a family member uses up or surpasses his or her own money, the other family members’ sums are unaffected.
Harry’s mother, for example, was admitted to the hospital for a kidney transplant when he was recuperating from surgery. He didn’t need to be concerned about insurance coverage. Harry and his mother both have $20,000 in insurance coverage. As a result, they didn’t have to be worried about the number of claims they filed or the amount of money they were covered for.
Focused individual protection
Regardless of family health difficulties, the insurance intends to cover an individual’s health risks. Harry, for example, required surgery to remove gallstones. He was well aware that having such a pre-existing ailment meant that the entire family would wait for coverage to begin.
This is the moment when a new insurance policy does not cover pre-existing conditions. Harry wanted to make sure that his physical issue didn’t put the rest of his family on hold. As a result, an individual policy that provided individual protection looked like the best option.
Risk v/s premium
When you acquire a family floater, the insurance company considers which family member poses the most risk. Family floaters can be pricey if you have high-risk folks, such as older citizens or those who have pre-existing ailments. In such instances, an individual health insurance coverage may be a better and less expensive choice.
Discounts and benefits
When purchased for several family members, most individual insurance policies provide savings and other perks. For example, in addition to his personal coverage, Harry purchased reduced individual policies for his parents and wife.
Individual tax benefit
Do you want to save money on taxes? Purchasing health insurance is tax-deductible! Any premiums you pay are deducted from your taxable income, reducing your tax obligations. The advantage increases if you are covering your parents, who are older citizens.
Choosing the best individual health insurance plan
There are various distinct types of health insurance plans, each with its own set of characteristics.
Health Maintenance Organization (HMO)
A health maintenance organization (HMO) is a business with a structure that enables them to provide insurance coverage to its members through a network of healthcare providers.
Typical HMO characteristics include paying a monthly or yearly fee for insurance coverage. HMO plans offer reduced premiums because physicians and other healthcare providers are steered to them. Still, subscribers are confined to a network of doctors, and other healthcare providers contracted with the HMO.
Preferred Provider Organization (PPO)
A preferred provider organization (PPO) is a form of insurance plan in which medical professionals and facilities offer discounted services to members. Preferred providers or in-network providers are healthcare providers who are members of this network.
PPO plan subscribers can access healthcare providers outside of the PPO network (out-of-network providers); however, the charges for seeing these doctors are higher.
Exclusive Provider Organization (EPO)
An exclusive provider organization (EPO) is a cross between a health maintenance organization (HMO) and a preferred provider organization (PPO). You can only get services from providers in a certain network if you have an EPO plan. Exceptions can be made in the event of an emergency.
Another feature of an EPO plan is that you may have to select a primary care physician (PCP). This is a general practitioner who will treat you for minor ailments and give preventative care. Furthermore, you normally do not need a referral from your primary care physician to see a specialist if you have an EMO plan.
High-Deductible Health Plan (HDHP)
A high-deductible health plan (HDHP) includes a few distinguishing features. It has a greater yearly deductible than other insurance policies, as the name indicates—the percentage of an insurance claim that the subscriber covers is referred to as a deductible. Monthly premiums for HDHPs are often cheaper.
This sort of plan is suitable for young or usually healthy people who don’t anticipate needing healthcare until they have a medical emergency or are involved in an unexpected accident.
Consumer-Driven Health Plan (CHDP)
HDHPs include consumer-driven health plans (CDHPs). Pre Tax monies are used to pay for a percentage of the services that customers get. CDHPs have greater yearly deductibles than other health insurance plans, like other HDHPs, but the subscriber pays cheaper monthly rates.
Point-of-Service (POS) Plan
Subscribers receive varying advantages from a point-of-service (POS) plan depending on whether they utilize preferred providers (in-network providers) or providers outside of the preferred network (out-of-network providers). A POS plan combines the benefits of both an HMO and a PPO plan.
Short-Term Insurance Policy
A short-term insurance policy fills in any coverage gaps that may arise if, for example, you move jobs and your new employer’s plan does not kick in right away.
It lasts around three months on average. The duration of the term varies by state, and you may be qualified for a 12-month short-term plan in some states.
Temporary health insurance, often known as term health insurance, is a type of short-term health insurance. It’s handy if you’re switching jobs, waiting to become Medicare-eligible, or waiting for a plan’s scheduled open enrollment period.
Catastrophic health insurance is a form of policy that is usually only accessible to people under the age of 30. To be eligible, the government must grant you a hardship exemption. Premiums for catastrophic health insurance are often cheaper than for other types of health insurance.
These plans are for those who can’t afford to pay a lot in insurance premiums every month but don’t want to be without coverage in the case of a major accident or sickness.
While catastrophic health insurance plans may have cheap monthly rates, their deductibles are often the highest.
More than 75% of individual health insurance consumers pick Bronze or Silver plans. Your state may have its own exchange for comparing and purchasing ACA insurance, or it may utilize Healthcare.gov, which is run by the federal government. Keep in mind that the exchange isn’t the only option.
State’s registered insurance brokers can also assist you in finding the best health plan to fit your requirements and budget. They’ll listen to your health-care preferences and utilize their knowledge to match your requirements to health-care alternatives both on and off the exchange.
Choosing a Deductible
Once you’ve settled on the sort of plan that’s right for you, you’ll need to figure out how much of a deductible you can afford. This is the amount you must pay for eligible healthcare treatments before your insurance plan begins to reimburse you.
What is the maximum amount of out-of-pocket medical expenditures you can afford each year? The larger your deductible, the cheaper your monthly payment will be with most health insurance policies. If your monthly financial flow is tight, a greater deductible may be necessary.
Another important factor to consider when choosing an insurance plan is the out-of-pocket maximum. Your health plan will cover the whole cost of approved benefits once you’ve spent this amount on deductibles and medical services through co-payments and co-insurance.
How can I get individual health insurance at less premium?
It is well known that the cost of health insurance premiums rises as one gets older. The explanation for this is simple: it is a widely held perception that health risks rise with age. Thus, buying individual health insurance at a younger age gives you an edge because the possibilities of paying a lower premium are higher.
While you cannot influence your age when it comes to lowering your health insurance premiums, you can manage your co-payment. You will undoubtedly minimize the amount of premium you pay for your health insurance coverage if you choose co-payment. A copayment is a predetermined amount of money that you (the client) agree to pay out of pocket at the time of the claim. Your premium will be cheaper if you pick a greater co-payment amount at the time of claim. However, be sure that your co-payment amount is within your budget and that you can easily cover it when filing a claim.
Furthermore, if you have not made any claims throughout the term of your health insurance policy, you may be eligible for premium savings in the form of a No-Claim Bonus at the time of renewal. The decrease in the premium you receive for not having claimed in the previous year is known as the No Claim Bonus (NCB) (s). Starting now, this discount can be accumulated on an annual basis.
While it is widely acknowledged that in today’s fast-paced and stressful world, everyone should benefit from health insurance, it is critical to emphasize that you should do your study before purchasing any such coverage. Do not get health insurance coverage without first learning about and comprehending its complexities. It’s vital to understand what your health insurance policy covers, but it’s also critical to understand what it doesn’t cover.
Simultaneously, carefully examine the terms and conditions listed in the policy language before selecting your health insurance coverage. Please do not hesitate to contact your insurance provider with any questions you may have regarding your health insurance coverage and benefits.
Pre-existing conditions are frequently excluded from health insurance coverage. Companies that cover such ailments do so after a certain number of years have passed after the policy was purchased. As a result, read the product details between the lines.
Look around for the finest prices and perks on the market. Never go by what comes first; instead, make your own decision, since with practically universal internet access, purchasing an individual health insurance coverage is not only affordable but also convenient.
Here are a few ways you might be able to save money on your health insurance.
- Check to see whether you qualify for federal assistance. If you buy your own health insurance, a government aid program may be able to help you pay for it. Your monthly premium payment is reduced by the Advanced Premium Tax Credit subsidy. The Cost-Sharing Reductions program can help you pay a lesser cost-share for medical services. Both of these initiatives are aimed at assisting low-income individuals.
- Check to see whether you qualify for Medicaid. To offer health care to low-income individuals and families, every state has a Medicaid program and a Children’s Health Insurance Plan (CHIP). To learn more about these programs and to see if you are qualified, contact your state’s Department of Insurance or Health Department.
- Check to see whether you qualify for Medicare. If you are 65 or older and handicapped, you may be eligible for Medicare, even if you are still working. For 2020, the regular monthly Medicare Part B (medical insurance) cost is $144.60. A Part A (hospital insurance) premium is not required for most persons who have worked for at least ten years and paid Medicare taxes.
- Choose a plan with a high deductible and a health savings account (HSA). This insurance plan type may save you money if you aren’t qualified for government assistance programs. High-deductible plans have cheap premiums, and many of them provide some preventative care. HSAs are health-savings accounts that you may use to pay for medical bills that your insurance doesn’t cover. A health savings account saves you money on taxes since the money you put in and take out is either tax-free or tax-deductible.
- Purchase a medical supplement plan as well as a high-deductible health plan. You may be able to save money by picking a high-deductible plan with supplemental insurance to assist pay for your expenditures if you get very ill or injured. Supplemental insurance protects you against particular health issues, including accidents, critical care, disability, and death. Premiums for these plans often range from $25 to $50 per month, and there are normally no deductibles.
Individual health insurance is appropriate for persons who are more susceptible to illnesses and health problems. A person with a higher risk of illness should be covered by a special fund. Individual insurance plans are also preferable for people who seek the security of an assured payout rather than a variable number.
It is also appropriate for consumers seeking lifelong renewability, as most individual health insurance policies have this feature. Individual health insurance plans are a fantastic alternative for young adults entering the workforce with a family that is already covered.
Consider all options before purchasing a health insurance plan to ensure that you are adequately insured. Individual health insurance coverage should be purchased in accordance with your financial goals. The ultimate goal is to be financially and emotionally healthy in the event of a medical emergency.
Whatever form of coverage you purchase, be sure it is from a recognized and financially solid insurer. After all, one of the key advantages of buying life insurance is that it helps create a sense of stability in an otherwise uncertain world. Financial strength ratings are an unbiased technique to judge whether a company will be there for your family in the future. Look for a provider with a “Superior” (A+) rating from a recognized insurance rating agency.
After studying all the basics regarding life insurance policies, it’s time to consult with someone who can aid you in selecting which form of life insurance is ideal for you. As you may expect, your age, financial circumstances, family status, and several other considerations will all play a role. A broker or financial advisor may assist you in choosing which form of policy is appropriate for you, how it can be customized to your needs, and what alternatives are available if the term, whole life, or universal life insurance does not satisfy your needs.
If you don’t have anybody to talk to about insurance, there are a lot of internet resources that may aid you in learning more about buying life insurance or even contact a local financial professional who can listen to your worries and direct you to the best option.