Individuals and Families
Private health insurance plans for individuals and families are suitable for those who are not eligible for coverage through an employer or government programs like Medicaid or Medicare.
What are individual and family health insurance plans?
Individual health insurance plans are designed for individuals who do not have access to government programs like Medicare or Medicaid or employer-sponsored health insurance plans. These policies cover medical expenses such as hospitalization, prescription drugs, and sometimes dental and vision services. The cost of individual health insurance can vary depending on factors like your age, location, and health history.
A health insurance policy typically includes a deductible, which is the amount of medical expenses you must pay out of pocket before the plan begins to cover costs. There are also copayments, which are the portion of medical expenses you pay after meeting the deductible, and an out-of-pocket maximum, which is the cap on the total amount you will have to pay for medical expenses. Family policies work the same way as individual plans but may have higher deductibles, out-of-pocket maximums, and monthly premiums.
of Oregonians are covered by health insurance
average amount per person* for a major medical individual health insurance plan.
By having an individual or family insurance plan, you can access medical care at a reduced cost, such as paying a $20 copay instead of the full cost of a $100 medical bill. Having insurance also provides peace of mind, knowing that you will be covered if you experience a major illness or injury, and that your medical expenses may be capped even if they exceed hundreds of thousands of dollars.
What's covered by a private insurance plan?
When you choose to enroll in an individual or family health insurance plan, you can expect coverage for the 10 essential health benefits, which include
- hospitalization,
- emergency services,
- outpatient services,
- prescription drugs,
- preventative and wellness services,
- pediatric services,
- maternity and newborn care,
- mental health and substance abuse care,
- rehabilitative services, and
- laboratory services.
The Affordable Care Act (ACA) mandates that these benefits are covered by private insurance plans.
How to enroll for a private health insurance plan?
If you’re not eligible for health insurance through an employer, you can purchase coverage in one of four ways:
Shop for quotes online: You can compare rates and policies from multiple insurance companies by requesting quotes from an online comparison tool. This method allows you to discover what plans are offered in your area and compare prices.
Buy directly from an insurer: If you know which insurer you want, you can directly purchase a plan from them. However, keep in mind that there are no discounts for buying direct.
Choose a marketplace plan: You can compare private health insurance plans from multiple companies on Healthcare.gov or your state’s health insurance marketplace. However, there are limitations on when you can enroll, and you can only purchase a plan during fall open enrollment or if you qualify for a special enrollment period due to certain qualifying situations. Additionally, those with low to moderate incomes may qualify for discounted health insurance under the premium tax credit program.
Shop through an insurance agent: If you already work with an agent for other types of insurance, they may also be able to assist you in selecting the best private health insurance policy.
Metal tiers of individual health insurance
Individual health insurance policies are classified into four metal tiers, which determine the amount of medical expenses the plan will cover. Typically, a higher-tier plan like Gold or Platinum will cover a greater proportion of medical costs, which makes them suitable for people who require regular or expensive medical care.
On the other hand, a cheaper health insurance plan in the Bronze or Catastrophic tier can help you keep your monthly bills low, but you may have to pay more when you visit a doctor. Regardless of their tier, every plan covers the same crucial health services. When selecting a plan, comparing the plan’s cost to its coverage can help you choose the most appropriate plan for your needs.
Bronze
This plan covers 60% of medical costs on average, leaving policyholders responsible for paying 40%. This plan has lower monthly premiums but higher deductibles and out-of-pocket maximums.
Silver
This plan covers 70% of medical costs on average, with policyholders responsible for paying 30%. This is the most popular option and offers moderate monthly premiums, deductibles, and out-of-pocket maximums.
Gold
This plan covers 80% of medical costs on average, leaving policyholders responsible for paying 20%. This plan has higher monthly premiums but lower deductibles and out-of-pocket maximums.
Platinum
This is the highest-tier plan that covers 90% of medical costs on average, leaving policyholders responsible for paying 10%. This plan has the highest monthly premiums but the lowest deductibles and out-of-pocket maximums.
What are the different types of ACA plans?
When selecting an ACA health insurance plan, it’s crucial to take into account factors such as your budget, location, and healthcare needs. The four primary types of plans available are Preferred Provider Organization Plans (PPOs), Point-Of-Service Plans (POSs), Health Maintenance Organization Plans (HMOs), and Exclusive Provider Organization Plans (EPOs).
1. PPO (Preferred Provider Organization Plans)
One of the most popular types of health insurance plans available to individuals and families are Preferred Provider Organization plans, which are also known as PPOs. With a PPO, you have the flexibility to choose any in-network healthcare provider without having to obtain a referral from a primary care provider. In-network services are typically covered at a higher benefit level than out-of-network care.
Generally, PPO plans require you to pay an annual deductible before the insurance company begins covering most services. You may also have to pay a co-pay (which can range from $10 to $30) or coinsurance for certain healthcare services.
A PPO plan could be a suitable ACA plan for you if you prefer to have the freedom to choose almost any medical facility or provider for your needs, desire some coverage for out-of-network care, and do not want to have to obtain a referral from your primary care provider to see a specialist.
2.HMO (Health Maintenance Organization Plans)
Health Maintenance Organization plans, also referred to as HMOs, provide a range of healthcare services through a network of providers who have agreed to offer these services to members. HMOs generally cover a wider variety of preventive healthcare services than other plans. Although HMOs typically have lower out-of-pocket expenses, you may be required to pay a deductible before your HMO starts covering its portion of covered healthcare services. Copays are often reasonable, and for services such as doctor’s office visits, you may be charged a copayment of $20-$35, and the HMO will cover the rest of the eligible charge.
There may be no deductible for the doctor’s visit. However, keep in mind that with an HMO plan, you may not be covered for non-emergency care received out-of-network or services obtained without a proper referral from your primary care provider.
An HMO plan could be a suitable ACA plan for you if you’re seeking a plan with a low monthly premium, prefer a plan with little or no deductible, and require mainly preventive care services.
3.POS (Point of Service Plans)
A Point of Service Plan (POS) combines some characteristics of both HMO and PPO plans, with the benefit levels varying depending on whether you receive care in-network or out-of-network. A POS plan is essentially a hybrid of HMO and PPO plans.
If you’re willing to coordinate your care through a designated primary care physician and your preferred doctor is within the plan network, then a POS plan could be a suitable ACA plan for you.
4.EPOs (Exclusive Provider Organization Plans)
An Exclusive Provider Organization plan (EPO) requires you to use only healthcare providers within the plan network, including doctors, specialists, and hospitals. While you don’t need a referral to see a specialist, you’ll be responsible for paying the entire medical bill if you seek non-emergency care outside the plan’s provider network without prior authorization from the plan.
If you prefer not to obtain a referral to see a specialist, and your preferred healthcare providers are within the plan network, an EPO plan could be a suitable ACA plan for you. Additionally, if you’re seeking a lower monthly premium than what is typically offered by an HMO or PPO plan, an EPO plan may be a good option for you.
FAQS
What is an individual health insurance plan? An individual health insurance plan is a policy that you purchase on your own, rather than through an employer. It is designed to provide financial protection against medical expenses for individuals who are not enrolled in a government program or a job-based policy.
What is a family health insurance plan? A family health insurance plan is a policy that provides coverage for multiple people, usually including spouses and children. It works similarly to an individual plan, but the deductible, out-of-pocket maximums, and monthly costs may be higher to cover the additional individuals.
What are the metal tiers of health insurance? The metal tiers of health insurance are Bronze, Silver, Gold, and Platinum. These tiers indicate how much of your medical costs the plan will cover. Bronze and Catastrophic plans have lower monthly costs but higher deductibles, while Gold and Platinum plans have higher monthly costs but lower deductibles.
The Bottom Line:
Individual and family health insurance plans can provide financial protection and peace of mind for those who are not enrolled in a government program or a job-based policy. When selecting a plan, it is important to consider factors such as the metal tier, monthly costs, deductibles, out-of-pocket maximums, and covered services. Shopping around and comparing multiple plans can help you find the best option for your individual or family needs.
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