Just over half of all people in the United States get health insurance through their jobs. Medicaid and Medicare (which are government insurance programs for low-income and elderly people) cover 37% of the population.
But what if you don’t qualify for a government insurance plan or get health insurance at your job? That’s where individual and family plans come in.
Individual and family plans are just what they sound like—health insurance that individuals or families can buy on their own. These plans are available directly from insurance companies or through the Health Insurance Marketplace.
How to get an individual and family plan
There are three main ways to get an individual and family plan:
Buy plans directly from an insurance company.
Choose a plan from the Health Insurance Marketplace.
Get help from an insurance agent or broker.
When to Sign Up
There are limitations on when you can sign up for health insurance. Open enrollment, which happens every fall, is a time when anyone can enroll in or change their health plan.
However, if you’re experiencing a significant life change or facing unexpected circumstances, you have options. Qualifying life events such as losing your insurance, having a baby, or getting married are triggers that enable you to change your health plan at any time of the year.
So, if you find yourself in a situation where you no longer have insurance, don’t worry! You can still take control of your healthcare by exploring and signing up for a new plan outside of the typical enrollment window. Your well-being matters and avenues are available to ensure you have the coverage you need.
Cost is important when choosing an individual and family plan. Your monthly cost, or premium, is based on your age, location, family size, plan category and tobacco use.
No matter which plan you choose, you can save on your monthly premium if you qualify for a premium tax credit. Some people may also qualify for cost-sharing reductions if they enroll in a Silver plan.
Marketplace plans come in four levels: Bronze, Silver, Gold, and Platinum. These levels don’t change the quality of care that you get. Instead, they refer to how you and your health plan share the costs of your medical bills. Don’t forget that all plans cover the complete cost of preventive care.
Bronze Plans: Bronze plans have the lowest monthly premiums but high deductibles. That means you may have to pay up to thousands of dollars a year before your health plan pays for your care.
Silver Plans: Compared to Bronze plans, Silver plans have a slightly higher monthly premium and a lower annual deductible. Many people qualify for extra savings on Silver plans. These are called cost-sharing reductions. Your eligibility for these savings is based on your household income.
Gold Plans: Gold plans have a high monthly premium but lower costs when you need care. Deductibles for these plans are usually low. A Gold plan is great for people who have chronic conditions and need a lot of care.
Platinum Plans: Platinum plans have the highest monthly premiums but the lowest costs when you need care. Deductibles are also very low. These plans can be pricey, but they are great if you are willing to pay a high premium because most other expenses will be covered by your plan.
It’s also important to think about network when choosing your health plan. A network is a group of hospitals, medical facilities, and providers that have contracted with an insurance company to provide care to their members.
Most insurers have online search tools to find providers in their network. This is a great tool to use especially if you already have a doctor you prefer to see. Choosing a plan with your doctor in-network can help you change insurance plans without disrupting your care.
Choosing the network that is best for you depends on your health care needs. The most common types of networks are:
Preferred Provider Organizations (PPO): PPO plans have a network of preferred providers for you to choose from. You can still receive care from hospitals and providers outside of your health plan’s network, but it will cost you more. You can also see most specialists without prior approval from your health plan.
Health Maintenance Organizations (HMO): HMO plans limit your care to the providers and facilities in their network. Care from out-of-network providers will not be covered except in emergencies. HMO plans are usually more affordable (lower monthly premiums), but you don’t have the same flexibility to choose providers like you do with a PPO plan. HMO plans also require your care to be coordinated through a primary care provider (PCP) who can refer you to specialty services as needed.
Exclusive Provider Organization (EPO): EPO plans are a combination of HMO and PPO plans. They are like HMOs in that you have a lower monthly premium. You are also limited to the providers in your health plan’s network (except for emergencies). They are like PPOs in that you do not need a referral from your primary care provider to see a specialist.
Point of Service (POS): POS plans are less common. They also combine features of HMO and PPO plans. Like HMO plans, you need a referral from your primary care provider to see a specialist. But, like PPO plans, you can still get care outside of your plan’s network for a higher price.
There are a lot of network options to choose from, and many of these options are available in all four metal levels. If you are feeling overwhelmed by your choices, a licensed insurance agent can help you decide what’s best for you and your family.