Understanding Individual Health Insurance and Why It’s Important

What is Individual Health Insurance?


Individual health insurance is available to individuals and families that purchase coverage on their own. Individual health insurance is regulated by the Affordable Care Act (ACA) and if you’re eligible, could include savings to lower your monthly premium. As you explore the key features of individual plans, you’ll gain a greater understanding of the importance of health insurance and why it’s an essential part of your health journey.

Who Needs Individual Health Insurance?


Individual health insurance is typically for individuals and families who don’t have access to an employer-sponsored plan or qualify for government-run health coverage. Examples of people who may consider an individual and family health plan include:

  1. Individuals who work part-time and don’t qualify for employer-sponsored coverage.
  2. Entrepreneurs, freelancers, gig workers, consultants, or contractors who don’t work for an employer and need an affordable healthcare solution.
  3. Early retirees who need to bridge the gap before they become Medicare-eligible.
  4. College students and recent graduates who may need to manage a gap in coverage.

Health insurance for individuals offers flexible solutions and options that are able to align with their health requirements and budget. These solutions address the diverse needs of individuals and families, offering a sense of security in today's dynamic healthcare landscape.



Common Features of Individual Health Plans


Individual health insurance plans are designed to provide a level of personalized coverage aligned with the unique healthcare needs of an individual or family. These plans offer a range of key features that make them a valuable investment in safeguarding both physical well-being and financial stability.

  1. Customizable Coverage Options: Individuals and families can choose from plans with different coverage levels for medical services. This flexibility helps ensure the member only pays for the coverage they need, avoiding unnecessary out-of-pocket costs.
  2. Network of Care Providers: A network of doctors, hospitals, clinics, and specialists ensures individuals and families have access to a range of care providersdoctors and hospitals for medical services, typically at a discounted rate compared to out-of-network providers.
  3. Preventive Care: Individual and family health plans include coverage for preventive services, such as annual check-ups, vaccinations, screenings, and wellness visits. These services are essential for early detection and management of potential health challenges.
  4. Emergency and Urgent Care: Life is unpredictable, and medical emergencies sometimes happen. Individual and family health plans cover emergency and urgent care services, providing necessary support during critical situations.
  5. Prescription Drug Coverage: Many individual and family health plans offer coverage for prescription medications. This feature is particularly important for individuals with chronic conditions who rely on consistent medication as part of their treatment plan.
  6. Maternity and Newborn Services: Individual and Family plans provide coverage for maternity care, including prenatal visits, childbirth, and postnatal care for the mother and child.
  7. Mental Health Services: Recognizing the importance of whole-person health, individual and family health plans often offer coverage for mental health services to support a member’s overall well-being.
  8. Out-of-Pocket Maximum: Individual and family health plans come with an out-of-pocket maximum (MOOP), which limits the amount an individual or family pays for covered medical services during their plan year. Once the MOOP is reached, the insurer covers the remaining costs for covered medical services.
  9. Flexibility of Coverage: Unlike employer-sponsored health plans that may be tied to a specific job, individual health insurance plans go with you, meaning individuals and families can retain the coverage even if they change jobs or employment status.
  10. Tax Advantages: Some individuals and families may be eligible for tax benefits, also known as subsidies, which help reduce or eliminate the monthly cost for coverage.

Understanding these key features is crucial when evaluating individual health insurance plans. By carefully considering each, individuals and families can select a plan that aligns with their health needs, lifestyle, and budget.



How Individual Health Insurance Costs Work


To understand how individual health insurance costs work, you’ll need to be familiar with these key terms:

  • Deductible: The amount you must pay out-of-pocket before your health insurer begins contributing to the costs for covered  medical services. It's important to know that certain services, like preventive care, are often covered by your insurer without having to first meet your deductible.
  • Copay: A fixed amount you pay for specific medical services or prescriptions, often at the time of the service. Copays are typically consistent and easy to predict.
  • Coinsurance: A cost-sharing arrangement where you and your health insurer each pay a percentage of covered medical expenses after you've met your deductible. 
  • Out-of-Pocket Maximum: The maximum amount you'll have to pay in a plan year for covered medical services. Once you reach your out-of-pocket maximum, your insurance plan covers 100% of your covered medical expenses for the remainder of the year. 


To illustrate how these key terms interact, let's consider a hypothetical scenario. Imagine you have an individual health insurance plan with the following benefit details:

  • Deductible: $1,500
  • Copay for doctor's visits: $30
  • Coinsurance: 20%
  • Out-of-pocket maximum: $5,000


In this scenario, you visit your in-network primary care doctor for a routine check-up. You pay a $30 copay at the time of the visit, and this cost is applied toward your out-of-pocket maximum.


Later in the year, you need minor surgery that costs $2,000. Since you haven't yet met your $1,500 plan deductible, you'll need to pay the full $1,500 to meet your deductible, and then 20% of the remaining $500 balance, $100, as coinsurance.


As the year progresses, you need additional medical services that collectively total $2,500. With your deductible met, you pay 20% coinsurance on this amount, or $500. At this point, your total out-of-pocket expenses for the year are $30 (copay) + $1,500 (deductible) + $100 (coinsurance) + $500 (coinsurance) = $2,130.


At this point, your total out-of-pocket expenses are still below your $5,000 out-of-pocket maximum. This means that for additional covered medical services for the remainder of the year, you will pay any copays or coinsurance until you’ve hit your $5,000 maximum. Your insurer will then cover any remaining in-network costs for covered medical services for the remainder of the plan year.   


You should note that getting medical services from out-of-network providers may come with different cost-sharing amounts between you and your insurer, which will end up costing you more for care. 


Understanding health insurance terms and how they apply to individual health insurance plan options can help you make informed decisions when selecting coverage. 



How to Purchase Individual Health Insurance


Two avenues exist for purchasing individual health insurance: On-Exchange (Marketplace) Plans and Off-Exchange Plans.


On-Exchange (Marketplace) Plans


Health insurance marketplaces, often referred to as exchanges, were established as part of the Affordable Care Act (ACA) to provide a centralized platform where individuals and families can compare, select, and purchase health insurance plans. Here's how on-exchange plans work:


Qualified Health Plans (QHPs): All plans offered on the exchange are Qualified Health Plans (QHPs), meaning they meet certain standards set by the ACA. This ensures that these plans cover essential health benefits.


Access to Financial Help: One of the key advantages of shopping on the exchange is the potential eligibility for premium subsidies and cost-sharing reductions. Eligibility for financial help is based on factors including household income and family size.


Coverage Tiers: On-exchange plans are categorized into different coverage tiers: Bronze, Silver, Gold, and Platinum. These metal levels represent varying levels of cost-sharing, with Bronze plans having the lowest monthly premium, but highest out-of-pocket costs, and Platinum plans having the highest monthly premium, but lowest out-of-pocket costs. In addition to premium subsidies, Silver plans offer cost-sharing reductions that help lower your deductible, copay, and coinsurance, if you qualify.


Open Enrollment Period: There's an annual open enrollment period when individuals and families can enroll in or make changes to their health plan. The open enrollment season typically runs from November 1 through January 15, in most states. Outside the open enrollment period, you generally need a qualifying life event (such as marriage, birth of a child, or loss of other coverage) to enroll in health coverage.


Off-Exchange Plans


Off-exchange plans, as the name suggests, are health insurance options that individuals and families can purchase directly from a health insurer. Here's what to know about off-exchange plans:


Flexibility: Off-exchange plans offer a wide range of coverage options, including plans that might not be available on the exchange. This provides more flexibility to choose coverage that best suits your needs and benefit preferences.


No Financial Help: Unlike on-exchange plans, off-exchange plans do not offer premium subsidies or cost-sharing reductions. This means you'll be responsible for the full monthly premium amount and your full share of the cost for covered medical services.


When deciding between on-exchange and off-exchange coverage, it's essential to explore the types of health insurance plans available and consider factors such as your budget, care needs, and eligibility for financial help. Regardless of the coverage path you choose, securing an individual health insurance plan is a proactive step toward ensuring your and your family’s well-being.

Shop Individual Health Plans

The importance of having health insurance is that it offers peace of mind in an unpredictable world. Evaluate your coverage options, explore on- and off-exchange plans, and invest in a healthier future for you and your loved ones.

Shop Plans . Opens in new window

Related Articles