A layman’s guide to individual health insurance

Building your foundation of essential knowledge about individual health insurance policies.

What is individual health insurance?

Regulated under state law, individual health insurance is coverage purchased by an independent person (like you), not provided by an employer. Although it is called individual health insurance, the available policies can cover your family.

When you say “cover,” what exactly does that mean? Individual health insurance can help pay for medical expenses for an illness, injury, or other condition. If you are unsure of the benefits of this coverage, consider the following:

• Accidents or health issues can occur at any time.
• Medical care can be incredibly expensive and is the number one cause of bankruptcy.
• Insurance companies can give you access to networks of doctors and hospitals with negotiated lower rates.

More specifically, individual health insurance plans must cover 10 essential health benefits, including:

• Ambulatory services
• Emergency services
• Hospitalization
• Maternity care
• Mental health care
• Prescription drugs
• Laboratory services
• Preventive and wellness services
• Pediatric services
• Rehabilitative and habilitative services and devices

How does individual health insurance differ from employer-based coverage?

Health insurance provided by your employer is also called group coverage. Companies perform research, select an insurance company, and choose plan options for employees. This is the status quo for many businesses. Since small businesses are exempt from the employer mandate, offering group coverage simply may not be an option.

People without access to employer health insurance plans can purchase individual health insurance, and there are several advantages:

1. You have choices. Select the insurance company, plan, and options that best fit you and your family’s needs.
2. You have control. Switch plans, options, or insurance companies without HR telling you what to do.
3. You have independence. Take it with you no matter when, where, and how you change jobs.

It is important to note that if your employer is able to offer affordable group coverage, you are not eligible for subsidies.

What do these health insurance terms mean?

Though there are dozens of terms in the realm of health insurance, there are four primary terms that you should understand.

Coinsurance: the percentage of your eligible medical expenses that you pay after your deductible has been met.

Copayment (Copay): the flat fee you pay each time you visit the doctor or fill a prescription. It may or may not count toward your deductible.

Deductible: the set amount you pay toward your eligible  medical expenses every year before your insurance company starts paying. This amount varies by plan.

Premium: the amount you pay your health insurance company in order to keep your coverage active. It is usually paid in monthly installments.

Are there reasons why you can’t get individual health insurance?

As of 2014, thanks to the Affordable Care Act (ACA), health insurance companies may no longer exclude, limit, or deny coverage to any American based solely on a pre-existing condition.

As a result of the ACA, most Americans can generally only purchase coverage during the Open Enrollment Period. This is a specific deadline you must meet in order to get coverage for the upcoming year. 

What if I miss the Open Enrollment Period?

If you happen to miss the Open Enrollment Period—which runs from November 1 to December 15— there are qualifying events that may allow you to still get a health insurance policy.

What affects the cost of individual health insurance premiums?

Remember the term premium? It was one of the four primary terms we talked about. Your premium is influenced by five factors.

Age: premiums may be as much as three times higher for older people.

Location: yes, where you live can affect your premium. Differences in competition, state and local rules, and cost of living account for the changes.

Tobacco use: tobacco users may be charged up to 50 percent more than those who do not use tobacco.

Single vs. Family: insurers may charge you more for a plan that also covers a spouse and/or any dependents.

Metal Levels: there are five metal levels. Bronze plans often have lower monthly premiums but higher out-of-pockets costs when you receive care. Platinum plans usually have the highest premiums but lowest out-of-pocket costs.

What are the five levels (sometimes referred to as tiers) of individual health insurance? 

• Bronze plans are designed to pay 60% of medical expenses.
• Silver plans are designed to pay 70% of medical expenses.
• Gold plans are designed to pay 80% of medical expenses.
• Platinum plans are designed to pay up to 90% of medical expenses.

The fifth is a catastrophic plan. For eligibility of this plan, an individual must be younger than 30 and receive a “hardship exemption” or an “affordability exemption.

How do I pick a health insurance plan?

You can pick a health insurance plan using HealthMarkets’ FitScore® technology. After answering some quick questions about your needs, we’ll scan the health insurance marketplace and rank plans side-by-side. That way, you can easily compare your options.

Start comparing individual health insurance plans with HealthMarkets today.