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EVERYTHING YOU NEED TO KNOW ABOUT INDIVIDUAL AND FAMILY PLANS

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. We’ll talk more about that in a minute.

This guide outlines everything you need to know about individual and family insurance. We’ll cover the basics like:

  • Who needs an individual and family plan
  • What individual and family plans cover
  • How to get an individual or family plan

And, we’ll cover some things to think about when choosing an individual or family plan, including:

  • Cost
  • Metal levels
  • Network

Let’s jump in!

THE BASICS

Who needs an individual and family plan?

Open enrollment is a yearly opportunity to change or update your insurance plan. The open enrollment period usually lasts for several weeks to give you and your family plenty of time to make the right decision about your health insurance.

To learn more about what health insurance is and how it works, click here.

What do individual and family plans cover?

Individual and family plans are required by law to cover 10 essential health benefits:

 

Ambulatory Care
  • Description – This is also called outpatient care—medical services you get without being admitted to a hospital. Physical exams, standard doctor appointments, and same-day surgeries fall under the umbrella of ambulatory care.
Emergency Services
  • Description – Emergency care includes hospitals, urgent care, and ambulances.
Hospitalization
  • Description – This includes surgeries and overnight stays.
Laboratory Services
  • Description – Blood work, screening tests, and imaging like X-rays or MRIs are examples of lab services covered by individual and family plans.
Mental Health Services
  • Description – Mental health services include counseling, prescription drugs, and other behavioral health and substance use disorder treatments.
Pediatric Care
  • Description – Pediatric care includes everything a child needs to stay healthy, like annual check-ups, dental, and vision care.
Pregnancy, Maternity, and Newborn Care
  • Description – All plans cover pregnancy and childbirth, even if your pregnancy begins before you have insurance. These plans also cover birth control and breastfeeding support at no cost.
Prescription Drugs
  • Description – Prescription drugs are medicines you cannot buy on your own at the store. You may need approval from your health plan before getting certain medications (except in emergency situations).
Preventive and Wellness Services
  • Description – Preventive services, like cancer screenings, annual physicals, and vaccines are covered at no cost to you—no matter what type of plan you have—when you get those services from an in-network provider.
Rehabilitative Services and Devices
  • Description – Rehabilitative services help you gain or recover skills and functions you may have lost when you were sick or injured. Medical devices that help you manage your conditions in daily life, like wheelchairs, CPAP machines, or oxygen tanks, are also covered.

Many individual and family plans offer extra benefits. These may include:

  • Adult vision care
  • Adult dental care
  • Discounts on gym memberships and other health-related services
  • Wellness incentives (money back for healthy habits like getting a flu shot each year)
  • Chronic disease management programs
  • And more

How to get an individual and family plan?

There are three main ways to get an individual and family plan:

  1. Buy plans directly from an insurance company: Search for plans on the insurer’s website. Many insurance companies offer comparison tools to see which of their plans are the best fit for you and your budget. If you already know which company you want to go with, this is a great choice.
  2. Choose a plan from the Health Insurance Marketplace: The Health Insurance Marketplace is an online shopping tool to help you compare health plans in your area. The federal government created the Marketplace as part of the Affordable Care Act (ACA) in 2010. You might have also heard this called Obamacare.
  3. Get help from an insurance agent or broker: Insurance agents (also called brokers) can help you understand your plan options based on your health care needs and budget. These services are free to use and are helpful if you aren’t sure what you want or need. Click here to search for an insurance agent through the Marketplace. You can also look for insurance agents near you using your preferred search engine.

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.

Big life changes allow you to change your health plan at any time of the year. This is called special enrollment. Having a baby, losing current insurance coverage, or getting married are common qualifying life events.

To learn more about open enrollment and special enrollment, click here.

CHOOSING AN INDIVIDUAL AND FAMILY PLAN

Now that you know a little more about what individual and family plans are, let’s talk about some things to consider when choosing a plan.

Cost

Cost is important when choosing an individual and family plan. Your monthly cost (called a premium) is based on five things:

  1. Age: Your monthly premiums increase as you age. That’s because your health care needs and the expenses that come with them increase too. But there are laws that limit how much you can be charged for your premium. For example, you cannot be charged more than three times what a 21-year-old (the baseline age) is charged.
  2. Location: Your zip code can affect your monthly insurance premiums. Your premiums can change based on the cost of living in your area and how much competition there is between insurance providers.
  3. Family size: Your monthly premium will be less if you are buying insurance for only yourself. Your costs will increase if you have a spouse or children on your policy.
  4. Plan category: Marketplace plans come in four metal levels: Bronze, Silver, Gold, and Platinum. Your costs will vary based on the category of plan you choose. Learn more about the differences between metal levels below. Catastrophic plans (which are low-cost plans with high deductibles) may also be available for some people.
  5. Tobacco use: Tobacco users have a high risk of developing serious health complications. Because of this, their premiums can cost up to 50% more than non-tobacco users. Many plans cover treatment to help you quit smoking. These treatments can help you be healthier and lower your premium in the future. It’s important to be honest about whether you use tobacco. Lying about tobacco use to lower your premium is insurance fraud and can cause serious legal consequences.

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. Four out of five people who have Marketplace plans are eligible for monthly premiums of $10 or less.

Learn more about cost-sharing reductions and premium tax credits here.

Metal Levels

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 cost of preventive care at 100%.

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.
Bronze plans are a good choice for healthy people who don’t go to the doctor a lot. These plans offer financial protection in worst-case situations when your medical costs get high. However, you need to pay more out of your own pocket for general medical care than at other levels.

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. Silver plans are a popular option.

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.

Network

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.

There are many types of networks. Choosing the network that is best for you depends on your health care needs. The most common types of networks are:

  1. 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.
    – PPO plans may be right for you if you want flexibility when choosing a provider (especially for services like mental health counseling or physical therapy) and are willing to pay a higher premium.

  2. 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. – HMO plans may be right for you if you want a lower monthly premium and are comfortable with a PCP coordinating your health care for you. If you choose an HMO plan, it’s important to find a PCP that you trust.

  3. 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. – EPO plans may be right for you if you want more affordable premiums and don’t need the flexibility of seeing out-of-network providers. This is also a good option if you still want to coordinate your own care without getting referrals.

  4. 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. – POS plans may be right for you if you want a slightly lower premium than a PPO plan and are comfortable navigating the health care system. If you choose to see an out-of-network provider, you may have to submit claims yourself and pay your provider’s costs upfront.

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.