Health Insurance

How Can Individuals Protect Their Health Insurance Benefits?

Health insurance is one of the most important financial decisions individuals and families face. Whether you receive coverage through an employer or purchase a policy on your own, understanding your options can help you make informed decisions about your healthcare and finances.

Employer sponsored coverage can provide valuable protection, but changes in employment, provider networks, or family circumstances can affect your coverage. For people who are self-employed, between jobs, retired, or otherwise without employer sponsored insurance, choosing the right individual health plan requires careful consideration.

An independent health insurance agent can help you understand the available options, compare coverage, and find a plan that fits your needs and budget.

Understanding Individual Health Insurance

Individual health insurance is designed for people who do not have coverage through an employer, spouse, former employer, or government health program.

Before comparing plans, it helps to understand the basic terms used in health insurance.

Deductible

A deductible is the amount you generally pay toward covered healthcare expenses before your insurance begins paying according to the terms of your plan.

Copay

A copay is a fixed amount you pay for certain covered healthcare services. For example, your plan may require a $25 copay for a primary care visit.

Coinsurance

Coinsurance is the portion of covered healthcare costs you pay after meeting your deductible. The insurance company pays the remaining covered amount according to the terms of your plan.

Out-of-Pocket Maximum

Your out-of-pocket maximum is the most you are generally required to pay during a plan year for covered services. Once you reach this limit, your plan generally pays the full cost of covered services for the rest of the plan year, subject to the policy terms.

Provider Network

A provider network includes doctors, specialists, hospitals, clinics, and other healthcare facilities that participate in a health plan.

Two common types of networks are Preferred Provider Organizations, or PPOs, and Health Maintenance Organizations, or HMOs.

When comparing plans, do not look only at premiums and deductibles. Check whether your preferred doctors, specialists, hospitals, and conveniently located healthcare facilities are included in the network.

Employer Sponsored Health Insurance

Health insurance can be an important factor when considering a new job. Employers may offer different levels of coverage, employee contributions, provider networks, and benefits.

Group health insurance can provide several advantages compared with individual coverage. Because employees participate as part of a larger group, the financial risk is spread across the organization. Employer contributions may also reduce the amount employees have to pay for coverage.

Depending on the employer's plan structure, employee contributions may be deducted from pay before taxes, which can reduce the effective cost of coverage.

When comparing employer sponsored plans, consider more than the monthly premium. Review the deductible, copays, coinsurance, out-of-pocket maximum, provider network, prescription coverage, and other available benefits.

Open Enrollment and Life Changes

Most employer health plans have an annual open enrollment period. This gives employees an opportunity to review their existing coverage and make changes to their health insurance elections.

Employees may also be able to change their coverage outside of open enrollment after certain qualifying life events.

Examples may include:

The specific rules depend on the plan and applicable regulations.

• Getting married
• Getting divorced
• Having a child
• Losing a spouse
• Experiencing another qualifying change in family or coverage status

What Happens When You Leave Your Job?

Losing employer sponsored coverage does not necessarily mean you have to go without health insurance.

Depending on your circumstances, you may be eligible for COBRA continuation coverage. COBRA can allow eligible employees and dependents to continue their employer's health plan for a limited period.

However, the employer generally stops paying its usual share of the premium. This means you may have to pay the full cost of the coverage, along with any permitted administrative fee.

For someone between jobs, that cost can become a significant financial burden. Depending on your circumstances, an ACA Marketplace plan may provide another option.

ACA Marketplace Health Insurance

The Affordable Care Act created a marketplace where individuals and families can compare and purchase qualifying health insurance plans.

Marketplace coverage can be an important option for people who do not have access to employer sponsored insurance and are not eligible for other government programs.

Health plans available through the Marketplace are generally grouped into four metal categories:

These categories help consumers compare how healthcare costs are generally divided between the insurance company and the policyholder.

Depending on your household income and eligibility, you may qualify for financial assistance that can reduce the cost of Marketplace coverage.

• Bronze
• Silver
• Gold
• Platinum

When Can You Enroll?

Marketplace plans generally have an annual open enrollment period. Certain life events may also make you eligible for a special enrollment period.

Qualifying events can include:

Enrollment periods and requirements can change, so review the current rules before selecting coverage.

• Losing employer sponsored coverage
• Getting married
• Getting divorced
• Having a child
• Moving to another state

What Does Marketplace Coverage Include?

Qualifying Marketplace plans are required to cover essential health benefits.

These include categories such as:

The ACA also provides protections for people with pre-existing health conditions. Marketplace insurers generally cannot deny coverage or charge higher premiums simply because someone has a pre-existing condition.

• Hospital care
• Emergency services
• Prescription drugs
• Maternity and newborn care
• Mental health and substance use disorder services
• Preventive care

Medicare and Medicare Supplement Insurance

Medicare is a federal health insurance program primarily serving people age 65 and older, along with certain younger individuals who qualify because of disabilities or other qualifying circumstances.

Understanding how Medicare works is important because Original Medicare does not cover every healthcare expense.

Medicare Parts A and B

Medicare Part A generally provides hospital coverage, while Part B generally covers physician services and other outpatient medical care.

Original Medicare does not have an annual out-of-pocket maximum for covered services. As a result, beneficiaries can face significant healthcare costs depending on their medical needs.

Original Medicare also does not generally cover routine dental, vision, or hearing services.

Medicare Supplement Insurance

Medicare Supplement insurance, also known as Medigap, is designed to help cover certain costs that Original Medicare does not fully pay.

Medigap plans are standardized, which helps consumers compare the benefits associated with different plan types.

Medicare Supplement coverage generally allows beneficiaries to see healthcare providers who accept Medicare without relying on a private insurance network.

Prescription drug coverage is generally handled separately through Medicare Part D.

The cost of Medicare Supplement insurance can vary based on factors such as the plan selected, location, insurer, and other pricing considerations.

Before choosing coverage, consider your healthcare needs, preferred providers, prescription medications, and budget.

Medicare Advantage

Medicare Advantage, also known as Medicare Part C, is offered by private insurance companies that contract with Medicare.

These plans provide Medicare Part A and Part B benefits and generally include prescription drug coverage. Some plans may also offer additional benefits such as dental services, vision coverage, hearing benefits, or fitness programs.

One important difference is how Medicare Advantage plans manage provider access. Many plans use HMO or PPO networks, which can include specific rules regarding providers, referrals, and out-of-network care.

When reviewing a Medicare Advantage plan, consider the premium, cost sharing, provider network, prescription coverage, and additional benefits.

Medicare Advantage vs. Medicare Supplement

Medicare Advantage and Medicare Supplement insurance work differently, so it is important to understand the differences before choosing coverage.

Medicare Advantage plans may offer additional benefits and different cost structures, but network restrictions and other plan rules may apply.

Medicare Supplement plans generally provide more flexibility when choosing providers who accept Medicare, but they typically require a separate premium and do not include prescription drug coverage.

Consider your healthcare needs, preferred doctors, prescription medications, budget, and the level of provider flexibility that is important to you.

Health Savings Accounts and High Deductible Health Plans

Some individuals choose a high deductible health plan, or HDHP, in exchange for lower monthly premiums.

When paired with an eligible Health Savings Account, or HSA, an HDHP can provide tax advantages while helping you set aside money for qualified medical expenses.

An HSA can provide several tax advantages:

Contributions may be tax deductible or made on a pre-tax basis through an employer.

Account earnings can generally grow without current federal income tax.

Withdrawals used for qualified medical expenses are generally tax free.

Unused HSA funds can generally remain in the account and carry forward from year to year.

For some individuals, an HSA can also provide funds for qualified healthcare expenses during retirement.

However, an HDHP can require you to pay more out of pocket when you receive medical care. Before choosing this approach, consider your healthcare needs, available savings, and ability to handle the deductible and other out-of-pocket costs.

Other Health Insurance Products

Health insurance helps cover medical expenses, but it may not replace income if an illness or accident prevents you from working.

Supplemental insurance products can provide additional financial support in certain situations. These policies are generally intended to complement health insurance rather than replace it.

Critical Illness Insurance

Critical illness insurance can provide a lump-sum benefit after the diagnosis of a covered condition.

Depending on the policy, covered conditions may include cancer, heart attack, stroke, kidney failure, or organ transplant.

The benefit is generally paid directly to the insured and may be used for medical expenses, household bills, transportation, lost income, or other financial needs.

Accident Insurance

Accident insurance is designed to provide benefits following a covered accidental injury.

The money can help with expenses that may arise after an accident, including medical bills, household expenses, or income-related needs.

Hospital Indemnity Insurance

Hospital indemnity insurance provides a predetermined benefit when you experience a qualifying hospitalization.

The benefit may be structured as a daily amount, an admission benefit, or another amount specified by the policy.

This coverage can provide additional financial support when a hospital stay results in significant out-of-pocket expenses.

How to Choose the Right Health Insurance

There is no single health insurance plan that works for everyone. Your healthcare needs, family situation, employment, finances, age, and preferred providers can all affect which type of coverage may be appropriate.

Start by reviewing your current situation and expected healthcare needs. Then compare the plans available to you.

Consider:

If you receive coverage through an employer, review your options during each open enrollment period.

If you need individual coverage, compare the Marketplace plans available in your state and determine whether you qualify for financial assistance.

If you are eligible for Medicare, compare your available options based on your healthcare needs, preferred providers, prescription medications, budget, and desired level of flexibility.

You may also need to consider other available benefits, such as VA healthcare or retiree health coverage from a former employer.

• Monthly premiums
• Deductibles
• Copays
• Coinsurance
• Out-of-pocket maximums
• Provider networks
• Prescription coverage
• Access to hospitals and specialists
• Employer contributions
• HSA or FSA options
• Available financial assistance

Review Your Health Insurance Regularly

Your healthcare and financial circumstances can change over time.

A plan that works well today may not provide the same value several years from now. Changes in employment, income, family circumstances, healthcare needs, or provider networks can all affect your coverage decisions.

Review your health insurance during open enrollment and whenever you experience a major change in your circumstances.

Because health insurance can be complicated, working with an independent insurance agent can help you understand your options and compare available coverage.

The goal is not simply to choose the lowest premium. It is to find coverage that provides the protection you need while fitting your financial situation.

If you are unsure which option may fit your needs, an independent insurance agent can help you review your choices and understand the coverage available to you.

Need assistance with your health insurance? Contact us today to discuss your options and get started.