Health Insurance simplified.

The easy way to compare & buy the right plan

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Everyone gets sick or has medical issues sometimes.  


So, buying health insurance coverage is a smart and proactive way to make medical expenses more predictable and guarantee peace-of-mind in the case of a severe illness or other health care concern.


Even though buying health insurance is a smart move, the actual purchasing process can be daunting.


There are many different types of coverage, lots of confusing terms are involved and sometimes legal requirements come into play.  


To make it easier on you, this guide will explain:

What is Health Insurance?

What is Health Insurance?

Health insurance is a product people can buy to help protect them against significant medical care expenses when they suffer from an illness or are hurt.


Consumers pay a set amount each month, called a premium, to a health insurance issuer or carrier.


Then, whenever they have a health concern, the health insurance carrier will pay all or a significant portion of their medical care costs. 

How Health Insurance Works

Health insurance coverage is a contract between you and your insurer.  


You agree to pay them a set amount per month, and then they pay benefits to you when you qualify for them, under specific terms.


Health insurance usually provides a consumer with a great deal of protection, but each policy has rules and requirements to follow.  


This chart explains some common aspects of health insurance contracts.

Cost-Sharing Requirements

Almost all health insurance plans require participants to pay something towards the cost of their medical care, beyond the monthly premium.


Called cost-sharing, there are three common mechanisms.


Deductible  Consumers generally have to pay providers directly for the entire amount of their deductible before the issuer begins paying for medical benefits.  


Certain services, like preventive care, may be covered by the policy before the deductible is satisfied.


Copayment– A fixed dollar payment consumers need to make at the point-of-care for specific services. Copayments do not count towards the plan deductible, and the amount can vary based on the service. 


Coinsurance – The consumer’s cost for a specific covered service, calculated as a percentage of the amount the insurer will pay for that service. 


For example, a consumer might need to pay a 20% coinsurance rate for a covered hospital stay.


Coinsurance generally starts after a person has met their deductible.  


Besides the cost-sharing requirements, health insurance contracts typically contain a maximum out-of-pocket limit.


Once cost-sharing expenditures meet this limit, the consumer’s financial liability for covered services besides the premium ends for the plan year.

Covered Benefits

Health insurance contracts do not cover every type of medical care service. State or federal laws require coverage of some services (like preventive care).


Other benefits may be excluded or limited.  For example, long-term nursing home care might be an excluded benefit.


Chiropractic care might come with a limit on the number of visits.

Network Requirements

Health insurance issuers typically negotiate fee-based contracts with specific providers and healthcare facilities, known as the plan's network.  


Coverage may be limited to the network except in emergencies, or consumers may have higher cost-sharing responsibilities for out-of-network care. 

Eligibility Rules

Typically, health insurance contracts contain eligibility rules.


They can relate to a person's age, employment status, dependent status, place of residency, citizenship status, and other factors.  

Coverage Rules

Many plans impose rules on participants that can impact the delivery of care and payment of claims.


For example, people may need to get prior approval before the policy pays for certain services.


If consumers do not follow these rules, then they may face coverage limitations or exclusions.

Prescription Drugs

Prescription drugs are an essential part of medical care, but in a typical health insurance contract, prescription benefits terms are very different than other types of medical care.


The cost-sharing rules can be different for RX benefits, there may be requirements about how prescriptions should be filled, and drug coverage is usually limited to a specific list of medications known as a formulary.

Additional Benefits

Lots of health insurance contracts include additional benefits that provide value to consumers.


Examples include a help-line staffed by a nurse, smoking cessation programs, and programs to help manage specific diseases and chronic illnesses.  


There may be rules and conditions surrounding these additional benefits.

Health Insurance Plans & Network Types

When people buy major medical health insurance coverage, they not only choose a health insurance company, but also pick a health plan design.


The plan design provides the framework for the coverage.


It outlines what benefits and providers a person has access to, and under what financial terms. 


These are the most typical health policy plan designs:

Preferred Provider Organizations (PPOs)


In this type of plan, people can choose any provider they wish.


There are few restrictions regarding specialists and consumers usually do not have to designate a primary care physician.


PPO health plans contract with specific doctors and hospitals to create a network of providers.


If a person seeks health care from an "in-network" provider, they will get better financial protection than if they go to an "out-of-network" practitioner or facility.


PPO plan designs can include a deductible and co-payments.


Consumers may also have to pay a coinsurance percentage of costs for some services once they have met their deductible.

Health Maintenance Organizations (HMOs)


With HMO coverage, people have to designate a primary care practitioner (PCP) to coordinate all of their medical care needs.


Consumers often need to get referrals from their PCP to see a specialist, and except in an emergency, they have to get their care from a defined network of doctors and hospitals.


If an HMO enrollee gets care from a non-network provider or seeks specialty care without obtaining prior approval, it might not be covered, or coverage may be limited.


Cost-sharing can be in the form of copayments, deductibles, and coinsurance.

Point-of-Service (POS) Plans


POS plans are a HMO and PPO hybrid model.  


People with POS coverage have to designate primary care practitioner (PCP) to coordinate their medical needs and usually have to obtain prior authorization before they see a specialist.


However, POS plan participants can seek care from both in-network and out-of-network providers.


Copayments for specific services, as well as a deductible, are common in POS plans.


Consumers may also have to pay a coinsurance percentage of costs for some services once they have met their deductible.

Exclusive Provider Organizations (EPO) Plans


EPOs is another hybrid plan design.  People with EPO plans only have coverage within a strict network of providers and healthcare facilities, unless its emergency care.  


However, EPO plan participants usually do not have to designate a primary care practitioner and have greater freedom when seeking specialty care.


Deductibles, copayments, and coinsurance are all standard cost-sharing models used in EPO plans.

Qualified High-Deductible Health Plans (HDHP)


This special type of health plan option can work with a tax-preferred health savings account (HSA).  


People have to satisfy a relatively high deductible before the plan pays for any medical expenses, except for preventive care.  


Qualified HDHPs have flexibility in the other aspects of their plan design, so some may work more like a PPO, and others may be more restrictive in terms of plan networks or care requirements.


The distinguishing feature of the HDHP is its high deductible, which needs to conform to federal limits

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Private Health Insurance Coverages

There are many ways people in the United States can obtain private health insurance coverage.  


Some of the most common are:

Employer-Sponsored Coverage

Most people get their health insurance coverage through their employer or the employer of a parent or family member.


Businesses may choose to sponsor a group health plan as a benefit to their employees and their families.


Employers frequently subsidize a large portion of employee premiums, and employees may have the option to finance their share of the premium on a tax-preferred basis. 


In an employer-coverage situation, you have to be eligible for benefits.


The business chooses the available health insurance plan designs and sets the premium rates and cost-sharing requirements for qualified plan participants. 


Sometimes an employer offers a choice of multiple plan options, and other times there is only one plan.


There usually is an annual open enrollment timeframe when eligible people can join, and people can also join or leave at other points during the year when they experience key life events.


Besides a traditional group health insurance coverage offered by a single employer, other ways people can get coverage through their job include union-sponsored plans and through a collective of employers working together to purchase health insurance coverage.

Association Health Plan Coverage

Sole proprietors and individual business owners sometimes join professional associations to purchase health insurance coverage.


Associations offer members coverage to harness the collective purchasing power of a large group of people.


Associations have to meet specific regulatory criteria to provide health coverage, and depending on the state and association plan, people may need to meet specific eligibility standards to qualify to buy AHP coverage.

Short-Term Limited Duration Insurance

People who only need health insurance coverage for a limited period often buy short-term, limited-duration insurance.


This coverage offers medical care benefits, but for a brief timeframe.


So, the scope of benefits and depth of coverage can be minimal. Short-term policy contracts always need to be for less than 12 months, and there is a 36- month renewal limit.


Some states do not allow short-term policies at all, and other states put tighter controls on the duration of the coverage.


Unlike comprehensive health insurance coverage, most health insurance consumer protection laws do not apply to short-term, limited-duration coverage.  


Insurers do not have to sell these policies to all individuals who apply for coverage.


Insurers can refuse to cover people due to their medical status, and they can exclude coverage of preexisting conditions. 


Accordingly, when people buy this coverage, they have to get a notice containing specific language to help them understand what they are buying.

Individual Health Insurance Coverage

People who are under age 65 and do not have access to employer-sponsored health insurance may buy private health insurance coverage on an individual basis. 


There are two ways to purchase individual major medical health insurance coverage.


One is through a health insurance exchange marketplace, and the other is through traditional private individual health insurance purchasing channels.  


Health insurance exchanges are a relatively new option that began offering coverage in 2014 as part of the Affordable Care Act.


These online marketplaces provide people with a centralized and streamline place to compare coverage options and also potentially access federal tax credits and cost-sharing assistance.  

Many states choose to have the federal government run their health insurance exchange through the website www.healthcare.gov, but some states operate their exchanges independently. 

Traditional private coverage is offered through private online channels, through individual licensed agents and brokers and directly from various health insurance issuers. 


Buying coverage this way sometimes referred to as “off-exchange” purchasing.


There are advantages of buying individual coverage "on-exchange" and "off-exchange."  


This chart outlines some of the positives of each choice.

Comparison of Buying Individual Coverage “On-Exchange” or “Off-Exchange”

Details

On-Exchange

Off-Exchange

You will purchase an ACA-Compliant Qualified Health Plans that meet all federal and state consumer protection standards for individual major medical coverage.

Cost-sharing assistance and premium tax credits are available for qualified purchasers.

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When you apply for coverage, you will be informed if you or your dependents are eligible for public program coverage through the Children’s Health Insurance Program (CHIP) or Medicaid.

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You can access free purchasing assistance through licensed health insurance agents and brokers.

Coverage can be purchased online through a user-friendly interface.

Plans available in every metal tier (Platinum, Gold, Silver and Bronze Coverage)

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There is a broader range of health insurance carriers offering more flexible (and potentially lower cost) plan options.

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Public Health Insurance Coverages

In the United States, various public-funded health coverage programs serve specific populations.


To get access to coverage through one of these programs, you need to meet the eligibility criteria.


The primary sources of public coverage in the United States are:

Medicare

The federal health coverage program for Americans who are age 65 and older also covers people of any age with specific disabilities or end-stage renal disease.  


There are four types of Medicare Coverage.  People are automatically enrolled in Part A when they turn 65.  


It covers inpatient hospitalization and skilled nursing care, hospice care, and home health care in some situations.  


People also can choose to enroll in Medicare Part B when they become Medicare-eligible, which covers outpatient care, doctors’ visits, preventive care, and medical supplies.


Together, Medicare Parts A and B are known as Original Medicare.


Beneficiaries may add Medicare Part D plans to Original Medicare coverage to provide prescription drug benefits.


Finally, some people elect to enroll in a Medicare Part C plan, which is more commonly known as a Medicare Advantage plan.


Private insurers administer Medicare Advantage plans, and they must cover all of the same things as Original Medicare.


Medicare Advantage plans often include benefits that aren't typically covered by Original Medicare, too, like vision, hearing, dental, prescriptions, and wellness program coverage.

Medicaid

This program, which operates as a partnership between the federal government and each state, provides medical care to eligible low-income people, including adults, children, people with disabilities, pregnant women, and some elderly adults.


Medicaid operates according to federal standards, but each state has program flexibility. 


So, the structure of benefits and eligibility criteria vary.

Children’s Health Insurance Program (CHIP)

CHIP is another state/federal partnership program that provides access to health insurance coverage to eligible children.  


Some states blend CHIP and Medicaid into one program and others have two separate programs available.

Veterans Administration Health Care

(VA Benefits) — Eligible veterans have access to subsidized health care provided through the Veterans Administration, using their providers. 


The type of coverage available is unique to each eligible veteran, but comprehensive benefits and supplementary coverage are options.

Supplemental Health Insurance

Supplemental Health Insurance

In addition to major medical coverage, some people buy supplemental health insurance products for additional, or different degrees of financial support.


These plans are not subject to many of the same health insurance protection laws that apply to comprehensive major medical coverage, so they sometimes are referred to as “excepted benefits.”


The types of supplemental health insurance products available can range significantly by geographic area.  


Some of the most common types of supplemental health insurance products sold are:

Medicare Supplemental Coverage (also called Medigap coverage)

Helps provide additional benefits and financial protection to people enrolled in Original Medicare.

Standalone Vision and Dental Coverage

Comprehensive medical plans rarely provide dental and vision benefits for adults.


Individual and small group plans have some responsibility to provide dental and vision coverage for children, but supplemental coverage is often necessary.

Critical Illness Coverage

This coverage provides additional financial benefits for people diagnosed with specific critical diseases.  


Cancer policies are one of the most common types. 

Fixed Indemnity Coverage

These plans pay people a specified dollar amount when they need various medical care services, including inpatient and out-of-patient care.

Hospital Indemnity Coverage

Similar to a fixed indemnity plan, this coverage pays supplemental benefits upon hospitalization to help pay for non-covered services and cost-sharing.

Disability Coverage

These policies help replace a portion of a person's income when experiencing either a short or long-term disability

Travel Health Insurance

Provides reimbursement for healthcare expenses incurred during a foreign or domestic trip.

Health Insurance Protections

There are many federal and state laws designed to protect private consumers who purchase major medical health insurance.


These measures require health insurance issuers to cover certain benefits and services, play claims fairly and not discriminate against any individuals with significant health needs.


Other protections affect the way health plans are priced, how they structure provider networks, and how much cost-sharing they may allow.


Many of the protections for health insurance consumers stem from a federal law passed in 2010 called the Patient Protection and Affordable Care Act.


This law is also commonly referred to as the Affordable Care Act, Obamacare, Health Reform, and the ACA.


The ACA's private health insurance market protections apply to major medical health insurance coverage.


Other types of plans, like short-term limited duration health insurance coverage, are not covered by the ACA. 

Protections for People with Preexisting Medical Conditions

One of the most important consumer protections created by the ACA is the requirement that in the United States, all new private major medical health insurance coverage must be issued to anyone who applies, regardless of any preexisting medical condition.  


Another critical feature of ACA-compliant health insurance coverage is that it can’t be rescinded or canceled retroactively.


The only exceptions are if a consumer fails to pay the policy premiums, commits fraud, or intentionally misrepresents their health status.


Under those circumstances, a person's coverage could be canceled or rescinded according to the terms of the policy contract.


If a person accidentally makes a mistake or leaves something out about their health when communicating with their health insurance carrier, coverage cannot be canceled.


If a health insurance plan wants to cancel someone’s coverage for a valid reason, the law requires at least 30 days of advance written notice.  


That way, consumers have an opportunity to correct the issue or appeal the decision.

Maximum Out-of-Pocket Limits

ACA-compliant individual and group plans all have annual maximum out-of-pocket cost limitations.


Once a person spends the maximum amount on deductibles, copayments, and coinsurance, then they have no other out-of-pocket cost responsibilities for the remainder of the plan year.


Their health insurance issuer must pay for all other covered benefits in full.


Policy premiums do not factor into the maximum out-of-pocket limit calculation.  


So, people still need to pay their policy premiums after they’ve reached their maximum out-of-pocket limit for the year. 

Preventive Care Coverage

All ACA-compliant plans must cover recommended preventive care services. 


When people get preventive care coverage, they do not have to pay any deductible, copayment, or coinsurance costs if they go to an in-network provider.


Examples of preventive care include vaccinations, cancer screenings, annual well-child visits, and many birth control methods for women.


The list of preventive services health insurers must cover without applying cost-sharing is based on the current recommendations of four expert medical and scientific bodies.


Their recommendations can change from year-to-year, so health insurance issuers have to monitor the latest activity.


Unless there is a safety issue, a health insurer doesn't have to cover a new or updated preventive recommendations without cost-sharing until the start of the next policy year.

10 Essential Health Benefits

In addition to covering preventive-care access without cost-sharing, the ACA requires health insurance policies that individual people buy directly to include coverage of ten categories of essential health benefits (EHBs).  


Small employer group health insurance needs to cover the ten categories of essential health benefits too.  


Essential health benefits are:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care (for children) 

Health insurance carriers must provide EHB coverage that is equal in scope to the benefits offered by a "typical employer plan."  


Each state establishes a specific benchmark plan to define typical employer group coverage of the EHBs.  


Then all individual plans and small group plans offered in that state must include benefits substantially equal to the way the benchmark plan covers the EHBs.

Lifetime and Annual Limit Prohibition

Health insurers cannot put lifetime or annual dollar coverage limits on what the ACA considers to be essential health benefits. 


Large employer plans and group plans that self-fund their benefits do not have to cover all of the EHBs like individual health plans and small business plans do.


However, if any health plan provides any essential health benefits coverage, then it cannot place an annual or lifetime dollar limit on that coverage. 


Plans can put an annual or lifetime dollar limit on spending for any healthcare services that are not EHBs.


For example, adult dental coverage included in a major medical plan might have maximum yearly and lifetime benefit specifications, because oral and vision care are only considered essential health benefits for children.  


Health coverage plans can also limit the number of covered visits or timeframes for specific services.  


For example, a policy might limit physical therapy visits to a certain number of weeks or a certain number of sessions.

Mental Health Care and Substance Use Disorder Insurance Coverage Protections

People who buy individual health insurance coverage (either on-exchange or off), or get coverage through a small employer group benefit plan, have access to mental health and substance use disorder services because they are essential health benefits.


State laws often also include mental health coverage protections for this population. 


Large employer group health plans and self-funded group plans do not have to cover mental health and substance use disorder services. 


However, many do, and if the policy does cover them, there cannot be any annual or lifetime dollar limits on that coverage.  


Also, the Mental Health Parity and Addiction Equity Act applies to almost all large group health plans that cover 50 or more employees. 


If employer plans of this size provide coverage for mental health care or substance use disorders, then they have to provide the same level of benefits for these services as they do for other medical and surgical benefits.  


Known as “parity protections,” these requirements ensure that cost-sharing requirements, treatment limits, and financial protections are equal for medical and mental health and substance use benefits.  

How much does health insurance cost?

The cost of health insurance is directly related to the cost of medical care in a given area.


Prices are based on expected health care claims costs and the need to maintain financial reserves in the case of catastrophic claims.


The individual states and the federal government both have regulatory authority over individual market health premium rates to ensure consumers pay reasonable prices.  


Federal law requires health insurers to spend a certain percentage of all health insurance premiums on medical care costs and healthcare quality initiatives.


If a health insurance issuer doesn't meet this minimum loss ratio requirement in a given year, then it has to issue premium rebates to its customers.    


The ACA also provides a framework to help individual health insurance consumers compare plans, benefits, and costs.


All individual major medical plans are assigned bronze, silver, gold, and platinum ratings based on the plan's actuarial value. 


Actuarial value is the percentage of the total average cost of essential health benefits that a plan covers within a given year.


Consumers can use these metal levels to easily comparing the depth of coverage by policy and a policy's out-of-pocket cost requirements.


The actuarial value levels by metal tier available in the individual market in every state are:


Platinum – 90 percent

Gold – 80 percent

Silver – 70 percent

Bronze – 60 percent


Platinum plans have the lowest out-of-pocket costs, but they are usually the most expensive policies in terms of premiums.  


Bronze plans come with high cost-sharing requirements, and provider networks might be limited, but they can be much more affordable than other types of coverage.

How Does an Individual Health Insurer Decide How Much Premiums Should Be?

Each person who buys ACA-compliant individual health insurance coverage pays a premium rate that is specific to them, based on a standardized framework established by federal law known as adjusted community rating.


Individual market health insurance carriers can only vary a person’s premium rates based on the following factors:

  1. Family size (individual or family coverage)
  2. Geography (each state is divided into rating areas)
  3. Age (the price for a 64-year-old can be no more than three times higher than an 18-year old in the same rating area) 
  4. Tobacco use (the rate for a smoker cannot be more than 1.5 times higher than for a non-smoker)

An individual health insurance carrier cannot factor things like a person's gender or medical history into their health insurance policy premium rate.  


This is true both when coverage is initially offered, and at all points during the policy contract, including when coverage is renewed.

Premium Tax Credits and Cost-Sharing Assistance​​​​

To help more people afford individual health insurance and reduce the number of uninsured Americans, the ACA created advance premium tax credits


These tax credits can subsidize the cost of individual health insurance coverage for eligible people.


But a person can only get a premium tax credit if they buy their coverage through a health insurance exchange marketplace.


The ACA exchanges make a person's initial eligibility determination for a premium tax credit when they apply for exchange-based coverage, but, like other income tax credits, the Internal Revenue Service (IRS) also regulates the subsidies.


To qualify:

  1. The person's modified gross household income must fall between 100 percent and 400 percent of the Federal Poverty Level. (People with lower incomes may be eligible for Medicaid or another coverage assistance program.)
  2. The person must file a tax return, and if married, the person cannot use the filing status of married filing separately.
  3. The person must enroll in individual insurance coverage through a health insurance exchange marketplace.
  4. The person must be ineligible for, or not offered, affordable coverage or minimum-value coverage through an eligible employer-sponsored plan.
  5. The person must be ineligible for coverage through a government program, like Medicaid, Medicare, or CHIP.

The amount of a person's tax credit depends on their income in comparison to the federal poverty level and the cost of coverage.


If an individual's adjusted gross household income is under 100 percent of the poverty level, the health insurance exchange marketplace may refer them to their state's Medicaid and or Children's Health Insurance Program to see if they qualify for benefits through those programs.

 

When a person qualifies for a premium tax credit, they can decide if the subsidy should go straight to their insurer and appear as a discount on their policy premium bill.


Or, a person can choose to get their tax credit later when filing taxes.


The credit is refundable, so a person can get it even if he or she has no federal income tax liability.

Cost-sharing Reduction (CSR) Program

Beyond the health insurance premium tax credits, lower-income people who buy individual coverage through a health insurance exchange marketplace may also qualify for cost-sharing assistance. 


The cost-sharing reduction (CSR) program applies to people who buy individual coverage through a health insurance exchange and have an adjusted gross household income of between 100 percent and 250 percent of the FPL. 


Eligible people get cost-sharing relief in the form of lower deductibles, copayments, and coinsurance if they enroll in a silver-level exchange-based plan.


The program also lowers their out-of-pocket maximum. 

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What to buy health insurance?

Open Enrollment

Health insurance carriers have to cover anyone who applies for individual major medical coverage even if the person has a preexisting medical condition.


However, federal law sets up an annual open enrollment period for all individual-market purchasers.


The goal is to prevent people from only applying for health insurance coverage when they think they’ll need it and then dropping the coverage once they no longer require medical treatment.


That means that if you want to buy individual-market health insurance coverage, you must do so during the yearly open enrollment dates.


Otherwise, you can be shut out of purchasing comprehensive individual medical coverage for an entire year.


The only exception to the open-enrollment window is if a person qualifies for a special enrollment period.


The dates of the annual open enrollment window for private individual health insurance coverage aren't set in stone like they are for the federal Medicare program.


The times and length of the annual individual market open-enrollment period have changed over the years.


Still, January 1 has remained consistent as the start date for the national individual coverage plan year.


In recent years, the open enrollment period dates for most states have been November 1-December 15.


If a person does not enroll in individual-market coverage during the annual open-enrollment window, then the only other way that person can obtain individual coverage later in the year is by qualifying for a special enrollment period (SEP).


Individuals who are eligible for a SEP must generally enroll in coverage within 60 days.


Generally, the following life events qualify a person for a special enrollment period:


Loss of Eligibility for Minimum Essential Coverage – This includes the loss of eligibility for employer-based coverage, losing eligibility for Medicare, Medicaid or CHIP, the expiration of COBRA, and turning 26 and losing access to a parent’s plan.


Household Changes – Marriage, divorce, loss of coverage eligibility due to the death of a family member, and having a baby or adopting a child are all considered to be household changes that may qualify a person for a SEP.


Change in Residence - A permanent move to a different ZIP code, county or state can lead to a SEP, as can other circumstances like a student moving to or from an out-of-town school, a seasonal worker moving for work purposes, a person who is moving to or from transitional housing or a person who is leaving incarceration.


Other events that may trigger a SEP include: if employer-based coverage no longer meets the ACA's affordability or minimum value standards, if you live in a state that hasn't expanded Medicaid and your income increases so you would now be eligible for a premium tax credit, if you become a member of a federally recognized Native American tribe, if you become a U.S. citizen if you are a victim of an enrollment error, if you are turned down for Medicaid or CHIP coverage, if you are the victim of domestic abuse if you gain dependent status as a result of child support order or court order, and other exceptional circumstances.

Who Should Buy Health Insurance?

At some point, every person faces medical issues.


Health insurance coverage provides critical financial protection and access to care when it is needed most, so every American should consider purchasing private coverage or enrolling in a public program, if eligible.    


When it comes to choosing, each individual and family must make their own decision about what type of health coverage is best for them.


Critical personal factors to consider are medical conditions, provider preferences, location, and budget.


Here are some common types of people who need health insurance coverage, and different kinds of policies and programs they might want to consider.

Person covered

Coverage Concerns

Types of Coverage

Children

No one needs more routine medical care than small children, and they also get sick a lot! Many children qualify for subsidized public coverage through the CHIP program, and so families should investigate this coverage as well as private options.

Individual or Employer-Sponsored Major Medical Coverage


CHIP

College Students

Most colleges require students to demonstrate that they have health insurance coverage to enroll.

Individual Coverage


Student Coverage Offered Through Their College or University 


Participating in a Parent’s Employer Plan

Adults under 26

People who are under age 26 have the option to stay on a parent's employer plan, if available, or seek out other coverage options.

Individual Coverage


Coverage Offered by their Employer


Participating in a Parent’s Employer Plan

Families with kids

Kids need to go to the doctor often for routine medical care. Many families qualify for CHIP coverage, which they can compare with other private coverage options. Plus, parents need to make sure that they have access to quality medical care and the ability to protect their families in the event of a severe health issue too!

Individual or Employer-Sponsored Major Medical Coverage


CHIP


Supplemental Benefits

People going through life transitions

When people leave jobs or go through other life transitions, they often have changing health insurance needs.

Short-Term Limited Duration Coverage


Continuation of coverage options that may be available through an employer-sponsored plan

Gig Economy Works and Sole Proprietors

People who work for themselves don't always have access to employer-sponsored health insurance coverage. So, they need to look at alternative ways of accessing major medical coverage. Given that they do not have a traditional workplace to support them should they encounter a severe medical issue or become disabled, solo practitioners also should look into supplemental benefits.

Individual Health Insurance Coverage


Association Health Plan Coverage


Coverage through an Employer-Sponsored Plan (If Eligible) Supplemental


Benefits like Disability Coverage

Early Retirees

People who retire early may not have access to group coverage any longer. However, they will still need medical care coverage to support their new lifestyle.

Individual Health Insurance Coverage


Continuation of coverage options that may be available through an employer-sponsored plan


Supplemental Coverage

Senior Citizens

Many people think all seniors simply have coverage through Medicare. But there is a wide array of options available under the Medicare program, as well as supplemental benefits and potential other retirement coverage options to consider.

Original Medicare Medicare


Part D Rx Benefits


Medicare Advantage


Medicare Supplemental Coverage Retiree Coverage through an Employer-Sponsored Plan


VA Benefits

Getting started with Health Insurance

While it may seem like the health insurance landscape is overwhelming, know that simply choosing to obtain health care coverage is a positive action.


So, think about you and your family's everyday medical needs, if you have any doctors or healthcare facilities that you like, and what you can realistically afford.


Also, when you compare coverage options, look at little extra benefits that cost little or nothing but mean a lot.  


Examples include: a friendly website, 24/7 customer service support, access to a help-line staffed by a nurse or other practitioner, wellness benefits, or medical program discounts.


Finally, do not be afraid to ask for help!  There are lots of resources available to help you make a sound health coverage decision.


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Jessica Waltman

Jessica Waltman is a licensed health insurance agent and business strategy consultant with more than twenty years of experience in health insurance markets, health policy, and executive leadership. Her area of specialty is taking complex insurance requirements and breaking them down so that anyone can understand them.

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