What is Private Health Insurance?

About Private Health Insurance

 

Private health insurance is coverage provided through an employer, or purchased directly by individuals and families to help cover medical care and related expenses.

 

Private insurance is different than government-run insurance programs, which offer public health insurance such as Medicare, Medicaid, and Children’s Health Insurance Plan (CHIP).

 

Private insurance plans for individuals and families typically offer a range of benefits, including coverage for doctor's visits, hospital stays, prescription medications, diagnostic tests, and other medical services. Private health insurance plans often include advantages when compared to public health insurance, such as more plans to choose from, access to a broader network of care providers, and fewer limitations for some medical services.

How Much is Private Health Insurance?

 

Private health insurance plans are typically paid through a monthly premium, which varies based on factors such as the level of coverage, the member’s age, tobacco use, and location. In some cases, employers may offer private health insurance as part of an employee benefits package, with both the employer and employee sharing the cost of the premium.

 

In addition to the premium, there are usually member out-of-pocket costs for care, including the plan deductible, copays, and coinsurance. It’s important to understand these health insurance costs and how they can impact your overall expenses.

 

Eligibility for premium subsidies and cost-sharing reductions (CSRs) may also impact the affordability of Individual and Family Marketplace plans.

 

Private vs. Public Health Insurance

 

Private health insurance and public health insurance (also known as government-run insurance programs) are two different approaches to providing healthcare coverage. Here's a comparison of both:

 

  1. Coverage and Benefits

Private Health Insurance: Both Individual and Family plans and employer-sponsored coverage offer a range of healthcare benefits including doctor visits, prescriptions, hospital care, and mental health services. Benefits also often include access to specialized care treatments, elective procedures, and alternative therapies. 

 

Public Health Insurance: Essential care service coverage is provided including doctor visits, hospital stays, emergency and preventive care, and prescription medications. However, benefits may be more limited compared to private insurance plans.

  1. Cost

Private Health Insurance: With employer-sponsored coverage, your employer often pays for a significant portion of your monthly health insurance premium. An Individual and Family plan premium depends on factors such as age, location, tobacco use, and the selected plan. Marketplace health plans offer financial help that could lower or eliminate your monthly premium. Typically, the deductible, copays, and coinsurance apply to employer-sponsored coverage and Individual and Family plans.

 

Public Health Insurance: Funded primarily through state and federal taxes, making health coverage more affordable or no cost for eligible individuals. Those enrolled in Medicaid have limited to zero out-of-pocket costs for care. Medicare members typically pay a monthly premium for coverage and part of the costs for care each time they receive a covered medical service.

  1. Accessibility and Wait Times

Private Health Insurance: Generally provides access to a wider network of care providers, which may result in shorter wait times for visits, diagnostic tests, and elective procedures. It typically also offers more flexibility in choosing in-network doctors and hospitals.

 

Public Health Insurance: Aims to ensure access to care services to all those eligible.  However, there may be longer wait times for certain services and specialized care due to high demand or limited number of available care providers.

  1. Coverage Continuity

Private Health Insurance: If you leave your job with an employer-sponsored health plan, your coverage typically ends on your last day of work or the final day of the month you left. You may be able to continue receiving coverage through your employer’s health plan with COBRA for up to 36 months, but this option is often costly because your employer is no longer contributing to the monthly premium. If you begin a new job, your new employer may offer health coverage, but the plan options, network of care providers, and out-of-pocket costs will likely differ.

 

Individual and Family insurance offers continuity of coverage even if a person changes jobs or experiences a gap in employment. These changes are known as qualifying life events (QLEs) – like a loss of job or divorce. QLEs offer an opportunity for individuals to enroll in a new health insurance plan or change an existing health plan to avoid a gap in coverage.

 

Public Health Insurance: Provides continuous coverage for eligible individuals, ensuring access to essential healthcare services regardless of employment status and many life changes.

 

Individual and Family Health Insurance

 

Individual and Family health insurance is designed to provide medical coverage for those who purchase their own health plan. Circumstances when individuals and families may consider purchasing health insurance include:

  1. Employment: Individuals who are not eligible for employer-sponsored health insurance, or do not have access to a health insurance plan through their employer.
  2. Self-Employment: Individuals who are self-employed or have their own business.
  3. Job Transition: Individuals who experience a gap in employer-sponsored health insurance when switching jobs.
  4. Loss of Coverage: Individuals who experience a loss of health insurance coverage due to reasons including job loss, expiration of COBRA, divorce, or reaching the 26-year-old age limit to be considered a child dependent on a parent’s health insurance policy.
  5. Ineligible for Public Insurance: Individuals and families who do not meet eligibility requirements for public health insurance programs, such as Medicaid or Medicare.
  6. Specific Healthcare Needs: Individuals or families with specific healthcare needs or medical conditions may opt for private health insurance plans that offer more comprehensive coverage, specialized treatments, or access to preferred healthcare providers or facilities.

 

How to Enroll in Individual and Family Private Health Insurance

 

Enrollment in Individual and Family private health insurance plans typically happens during the annual Open Enrollment Period. Open Enrollment runs from November 1 through January 15, but actual dates can vary by state. During Open Enrollment, you can compare, shop, and enroll in a plan through the Health Insurance Marketplace, or directly through Anthem (off-exchange). 

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