Your options if you're not eligible through your employer
If your employer doesn't offer you health insurance as part of an employee benefits program, you may be looking at purchasing your own health insurance through private insurance.
A premium is the amount of money an individual or business pays to an insurance company for coverage. Health insurance premiums are typically paid monthly. Employers who offer an employer-sponsored health insurance plan typically cover part of the insurance premiums. If you need to insure yourself, you'll be paying the full cost of the premiums.
It is common to be concerned about how much it will cost to purchase health insurance for yourself. However, there are various options and prices available to you based on the level of coverage you need.
- You may need to purchase individual healthcare coverage if you just turned 26, are unemployed or self-employed, work part-time, are starting a business that will have employees, or have recently retired.
- If you do not have the option of enrolling in an employer-sponsored health insurance plan, a good source for gaining insurance coverage is through the Health Insurance Marketplace that was created in 2014 by the Affordable Care Act (ACA).
- If you are at least 65 or disabled, you can enroll in Medicare, with the option to add additional coverage through a private Medigap or Medicare Advantage plan.
How Buying Private Health Insurance Works
Some Americans get insurance by enrolling in a group health insurance plan through their employers.
Medicare provides health care coverage to seniors and the disabled, and Medicaid has coverage for low-income Americans.
Scenarios When You Might Need Private Health Insurance
There are certain circumstances that make it more likely that you will need to purchase your own health insurance plan:
A Young Adult 26 Years of Age or Older
Under the provisions of the Affordable Care Act (ACA) of 2010, young people can be covered as dependents by their parents' health insurance policy until they turn 26 years old. After that, they must seek out their own insurance policy.2
If you lose your job, you may be eligible to maintain coverage through your employer's health insurance plan for a period of time through a program called the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA allows eligible employees and their dependents the option to continue health insurance coverage at their own expense.
While coverage through COBRA can be maintained for up to 36 months (under certain circumstances), the cost of enrolling in COBRA is very high. This is because the formerly employed person pays the entire cost of the insurance. Typically, employers pay a portion of healthcare premiums on behalf of their employees.
A Part-Time Employee
Part-time jobs rarely offer health benefits. A part-time job is any position that requires employees to work a lower number of hours than would be considered full-time by their employer, or 40 hours per week. If you work part-time, you usually must enroll in your own health insurance.
A self-employed person may work as a freelancer or own a business. Some self-employed people can get health insurance through a spouse's plan. If not, they must provide their own health insurance.
A Business Owner Who Has Employees
If you start a business and you have employees, you might be required to offer them health insurance. Even if it's not required, you might decide to offer health insurance in order to be a competitive employer that can attract qualified job candidates. In this situation, you will be required to purchase a business health insurance plan, also known as a group plan.
If You Retire (or Your Spouse/Parent Retires)
When you retire, you will likely no longer be eligible for employer-sponsored health insurance. If you are under 65 and not disabled, you will need to purchase individual private health insurance until you turn 65 and can apply for Medicare. Many retirees choose to purchase private Medigap or Medicare Advantage plans in addition to Medicare as a way of guaranteeing more comprehensive coverage. Some retired people may also decide to completely replace Medicare coverage with a private Medicare Advantage plan.
It is important to note that Medicare, Medigap, and Medicare Advantage plans are only for the individual—your spouse, partner, and any dependents cannot be insured through your Medicare plan. This means that if your family was previously insured through your employer's plan, and you retire, your family members may need to enroll in individual insurance plans.
Dropped By Your Existing Insurer
Although the Affordable Care Act prevents insurers from canceling your coverage–or denying you coverage due to a pre-existing condition or because you made a mistake on your application—there are other circumstances when your coverage may be canceled. It's also possible that your insurance may become so expensive you can’t afford it.
Why You Should Purchase Health Insurance
If you find yourself in one of the above situations and lack health insurance coverage, it's important to enroll in an individual plan as soon as possible. (The fine for failing to obtain coverage was canceled in 2019.)
Even though you're not required to have insurance, you cannot predict when an accident will occur that will require medical attention. Even a minor broken bone can have major financial consequences if you're uninsured.
If you purchase insurance through the Health Insurance Marketplace, you may be eligible for income-based premium tax credits or cost-sharing reductions. The Health Insurance Marketplace is a platform that offers insurance plans to individuals, families, and small businesses.
The Affordable Care Act established the marketplace as a means to achieve maximum compliance with the mandate that all Americans be enrolled in health insurance. Many states offer their own marketplaces, while the federal government manages an exchange open to residents of other states.
While you may not be able to afford the same kind of plan an employer would offer you, any amount of coverage is more advantageous than going without. In the event of a major accident or a long-term illness, you will be prepared.
Choosing the Best Insurance Plan For You
There are several different kinds of health insurance plans, and each of these plans has a number of unique features.
Health Maintenance Organization (HMO)
A health maintenance organization (HMO) is a company that's organizational structure allows them to provide insurance coverage for their subscribers through a specific network of healthcare providers.
Typical features of an HMO include paying for insurance coverage for a monthly or annual fee. Premiums tend to be lower for HMOs because health providers have patients directed at them, but the disadvantage is that subscribers are limited to accessing a network of doctors and other healthcare providers who are contracted with the HMO.
Preferred Provider Organization (PPO)
A preferred provider organization (PPO) is a type of insurance plan in which medical professionals and facilities provide services to subscribed clients at reduced rates. Healthcare providers that are part of this network are called preferred providers or in-network providers.
Subscribers of a PPO plan have the option of seeing healthcare providers outside of this network of providers (out-of-network providers) but the rates for seeing these providers are more expensive.
Exclusive Provider Organization (EPO)
An exclusive provider organization (EPO) is a hybrid of the HMO and a PPO plan. With an EPO, you can only receive services from providers within a certain network. However, exceptions can be made for emergency care.
Another characteristic of an EPO plan is that you may be required to choose a primary care physician (PCP). This is a general practitioner who will provide preventative care and treat you for minor illnesses. In addition, with an EMO plan, you usually do not need to get a referral from your PCP in order to see a specialist physician.
High-Deductible Health Plan (HDHP)
A high-deductible health plan (HDHP) has a couple of key characteristics. As its name implies, it has a higher annual deductible than other insurance plans. A deductible is the portion of an insurance claim that the subscriber covers themselves. High-deductible health plans typically have lower monthly premiums.
This type of plan is ideal for young or generally healthy people who don’t expect to demand healthcare services unless they experience a medical emergency or an unexpected accident.
The last defining feature of a high-deductible health plan is that it offers access to a tax-advantaged Health Savings Account (HSA).
An HSA is an account that subscribers can contribute funds to that can later be used for medical costs that their high deductible health plan doesn’t cover. The advantage of these accounts is that the funds are not subject to federal income taxes at the time of the deposit.
Consumer-Driven Health Plan (CHDP)
Consumer-driven health plans (CDHPs) are a type of high-deductible health plan. A portion of services that subscribers receive is paid for with pre-tax dollars. Like other high-deductible healthcare plans, consumer-driven health plans have higher annual deductibles than other health insurance plans but the subscriber pays lower premiums each month.
Point-of-Service (POS) Plan
A point of service (POS) plan provides different benefits to subscribers based on whether or not they use preferred providers (in-network providers) or providers outside of the preferred network (out-of-network providers). A POS plan includes features of both HMO plans and PPO plans.
Short-Term Insurance Policy
A short-term insurance policy covers any gap you might experience in coverage if, for example, you change jobs and your new company plan doesn't kick in immediately.
It typically lasts for three months. Term lengths vary by state, and in some U.S. states, you may be eligible for a short-term plan for up to 12 months.
Short-term health insurance is also called temporary health insurance or term health insurance. It can be useful if you're changing jobs, waiting to become eligible for Medicare coverage, or waiting out the designated open enrollment period for a plan.
Under a short-term insurance plan, your spouse and other eligible dependents may also be covered. However, one important caveat of a short-term insurance plan is that in some cases, pre-existing conditions can disqualify you from coverage. The definition of a pre-existing condition varies depending on the state you live in, but it is usually defined as something you have been diagnosed with or received treatment for within the last two to five years.
Catastrophic health insurance is a type of insurance plan that is typically only available to adults ages 30 or younger. In order to qualify, you must receive a hardship exemption from the government. Catastrophic health insurance typically has lower premiums than other health insurance plans.
These types of plans are intended for people who cannot afford to spend very much money every month on insurance premiums but who don't want to be without insurance in the event of a serious accident or illness.
While catastrophic health insurance plans may have low monthly premiums, they typically have the highest possible deductibles.
Choosing a Deductible
Once you've decided on the type of plan that is best for you, you'll need to determine how much you can afford to pay as a deductible. This is the pre-determined amount you pay for covered healthcare services before your insurance plan starts to pay.
What can you afford to pay in out-of-pocket medical expenses each year? With most health insurance plans, the higher your deductible is, the lower your monthly premium will be. If your monthly cash flow is low, you might have to opt for a higher deductible.
Another key consideration when selecting an insurance plan is the plan's out-of-pocket maximum. After you've spent this amount on deductibles and medical services through co-payments and co-insurance, your health plan will pay the entire cost of covered benefits.
How Much Does Private Health Insurance Cost?
While many people are scared by the prospect of purchasing their own insurance versus enrolling in an employer-sponsored plan, some studies have shown that it can end up being more affordable than employer-sponsored plans.
A study from the Kaiser Family Foundation found that the average monthly premium for an employer-sponsored insurance plan for individual coverage in 2019 was $603. It was $1,725 for family coverage.
Conversely, according to the Kaiser Family Foundation, if you were to purchase your own insurance outside of an employer-sponsored plan, the average cost of individual health insurance was $440. For families, the average monthly premium was $1,168.
In addition, if you end up purchasing coverage through the Health Insurance Marketplace, you may qualify for a Cost-Sharing Reduction subsidy and Advanced Premium Tax Credits. These can lower the amount you pay for premiums, as well as lowering your deductible, and any co-payments and co-insurance you are responsible for.
Where to Go to Buy Private Health Insurance
You have several options when it comes to buying private health insurance.
If you are (or are soon to be) retired, you can begin on the website for Medicare. It is recommended that you see what the standard Medicare plan covers and then look at options for ways to supplement Medicare through Medigap and Medicare Advantage policies.
When considering Medigap or Medicare Advantage coverage, it’s important to understand how both work types of coverage work in conjunction with standard Medicare coverage.
As a result of the Affordable Care Act (ACA), the Health Insurance Marketplace was created in 2014. You can visit the Health Insurance Marketplace website to find out more about the options for health insurance coverage that are available where you live. You can also determine if you qualify for any subsidy and apply for it.
The Health Insurance Marketplace has a specific open enrollment period. Typically, it is between November 1 and December 15 every year, although various events may lead to the open enrollment period being extended or reopened.
The website includes information about private plans that are available for purchase outside of the Marketplace. However, if you purchase a plan outside the ACA's Marketplace, whether during open enrollment or not, you will not be eligible for any subsidies available under the ACA.
Under certain circumstances, an individual may be eligible to purchase a healthcare plan through the exchange even if it is outside of the specified open enrollment period. This is called a Special Enrollment Period. You may be eligible for a Special Enrollment Period if you experience a household change, including getting married or divorced, having or adopting a child, a death in your family, moving, losing your health insurance, being in a national catastrophe, or experiencing a disability.
The American Rescue Plan of 2021 increased subsidies for ACA plans for lower-income Americans and broadened subsidies to include some subsidies at higher income levels.11
Private Health Insurance Companies
You can visit the websites of major health insurance companies in your geographic region and browse available options based on the type of coverage you prefer and the deductible you can afford to pay.
The types of plans available and the premiums will vary based on the region you live in and your age. It's important to note that the plan price quoted on the website is the lowest available price for that plan and assumes that you are in excellent health. You won't know what you'll really pay per month until you apply and provide the insurance company with your medical history.
Pricing and the type of coverage can vary significantly based on the health insurance company. Because of this, it can be difficult to truly compare the plans to determine which company has the best combination of rates and coverage. It can be a good idea to identify which plans offer the most of the features that you require and are within your price range, and then to read consumer reviews of those plans.
If you're choosing a family plan or you are an employer who is choosing a plan that you'll provide to your employees, you'll also want to consider the needs of others who will be covered under the plan.
Key Factors for Choosing a Plan
Health insurance plans offer a variety of different features. While it may be hard to find a plan that offers everything you desire, consider which of the following features are the most medically and financially necessary. Here are some questions to consider when you are researching plans:
- Does the plan offer prescription drug coverage? Does it only cover generic versions of prescription drugs? What is the co-payment (also referred to as the co-pay) on generics and name-brand drugs? Check the medicines you're already taking, if any.
- What is the office visit co-payment, and does the plan have instituted a maximum number of office visits that it will cover per year?
- What is the co-payment for specialized services, such as x-rays, lab tests, and surgery? For an emergency room visit?
- Do you want a plan that allows you to add-on vision and dental coverage?
- Do you need pregnancy benefits?
- Do you already have a doctor you like? If so, you might want to find a plan that includes your doctor in its insurance company's provider network.
- Do lifetime and annual maximum benefits apply? The ACA effectively eliminated lifetime and annual maximums for essential medical services, but this does not include, for example, dental and vision coverage.
- Does the plan offer free or discounted services for preventive care, such as an annual checkup? Most plans under the ACA provide free coverage for most preventative care services. Short-term insurance plans and catastrophic coverage may not.
- Does the plan cover specialty services such as physical therapy, chiropractic, and acupuncture visits?
- What hospitals are included in the network?
- For PPOs, what is the cost for out-of-network services, should you want or need them? Can you afford this?
The Bottom Line
Getting your own health insurance policy is not be as easy as signing up for an employer's plan but at least you have control over the plan you get. Once you figure out what you need and become familiar with the terminology used to describe health insurance plans, your research will become easier. With the number of options available, you can probably find a plan that meets your needs—and your budget.
If you need help with your health insurance options, agents are available.IHealthagents.com
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