Finding the best health insurance for you and your family isn’t easy. You can find so many different health insurance companies and plans available that insurance agents even find it confusing at times. Fortunately, there are ways to do your own unbiased research and find a plan that meets your needs.
Jump ahead to these sections:
- What Is Individual Health Insurance?
- How Does Health Insurance Work?
- What Are the Different Types of Health Insurance?
- What Are the Key Features of Health Insurance Policies?
- How Do You Know if You Need an Individual or Supplemental Health Insurance Plan?
- How Do You Get Health Insurance Coverage?
- How Do You Pick an Individual or Supplemental Health Insurance Policy?
- Popular Private Health Insurance Companies in the US
- Buying Health Insurance: Frequently Asked Questions
What’s the most important factor when you’re looking for health insurance? Cost is an important factor but it’s most important for an insurance company to pay your healthcare provider as you expect it to.
This article will help you shop smart for health insurance and protect yourself financially from unexpected events that can lead to a financial catastrophe. Let’s take a look at health insurance together.
What Is Individual Health Insurance?
As the name implies, individual health insurance is coverage that you purchase on your own, independent from an employer or other group affiliation. You approach the insurance company as an individual or family so you don’t have to pay out-of-pocket costs when you have to receive care from a doctor, hospital, or another healthcare provider.
The biggest difference between an individual policy and group health insurance is the monthly cost, also known as the premium. Because companies approach insurance companies with many employees and spread the risk out for the insurer, those employees receive lower rates than if you were to apply for coverage on your own. The actual coverage an individual policy provides does not differ greatly from the benefits of a group insurance plan, but it does depend on the plan you select.
How Does Health Insurance Work?
Ideally, your health insurance company will provide payment to your healthcare provider once a claim is submitted. This relieves you of the responsibility of having to pay the provider out of your own pocket. Most providers work directly with the insurance company to process your claim. Next, the insurance company provides payment on your behalf to the provider.
This is how health insurance is supposed to work, in theory. Unfortunately, there are occasions where the insurance company may not agree with the amount the provider charges for a given service or it may claim that your policy doesn’t cover the services you received. If the amount charged is disputed by the insurance company, the healthcare provider will communicate with the insurance company and work out the details.
However, if the insurance company indicates the services you received aren’t covered, it normally becomes your responsibility to deal directly with the insurer to get clarification on why your claim is denied.
Besides the high cost of premiums that accompany individual health insurance plans, communicating with the insurance company is the second biggest hurdle people face with their coverage. Fortunately, most providers will verify that your procedure is covered before you receive treatment and they’ll also verify how much the insurance company will pay for the treatment.
Knowing this information in advance can save you time and reduce stress at a time when your focus should be on getting or staying well.
How much does an individual policy typically cost per month?
What you’ll pay for individual health insurance will vary greatly depending on a number of different factors. These include your:
- Location
- Age
- Health history
- Insurance provider
- Coverage selected
According to the online insurance source eHealth, individual policy cost average in the U.S is $440 for an individual and $1,168 for a family. Compared to the premiums you’d pay for group health coverage, premiums for individual health insurance are considerably higher.
What does health insurance typically cover or not cover?
What is covered by health insurance will vary from plan to plan. For example, you can find plans available that cover only hospital stays and don’t cover doctor’s office visits. You can also find plans that provide comprehensive coverage but won’t cover certain procedures. For example, almost no individual health insurance policies cover elective procedures such as cosmetic surgery.
Currently, the Affordable Care Act (ACA) is still available to you if you want to purchase an individual policy. Policies are available through an exchange and outside of the exchanges that deal directly with insurance companies.
All individual health plans must cover a standard set of 10 essential health benefits with the ACA:
- Outpatient care, including doctor visits
- Emergency room visits
- Hospitalization
- Pregnancy and maternity care
- Mental health and substance abuse treatment
- Prescription drugs
- Services and devices for recovery after an injury or due to a disability or chronic condition
- Lab tests
- Preventive services, including health screenings, immunizations, and birth control. You pay $0 out of pocket for preventive care when you see healthcare providers in a health plan’s network.
- Pediatric services, including dental and vision care for children
How do premiums, claims, and payouts usually work?
Premiums, claims, and payouts are three facets of any individual health insurance plan.
Premiums help insurance companies spread the risk out over large employer-sponsored plans. Premiums are lower for these than they are for individual plans.
Premiums are most often deducted straight from your bank account or through your paycheck by the insurance company, which helps the insurer retain insurance in force and helps maintain your premium payments.
Claims are usually filed electronically by the healthcare provider. This is usually a streamlined process that has been perfected over the years by insurance companies to facilitate quick payment to a healthcare provider.
If a claim is denied, the insurance company will notify both you and your provider. The provider will then contact you to pay any unpaid balances.
The payment to the healthcare provider for services rendered will normally be made directly by the insurance company, saving you from having to pay money upfront before you receive care. However, you will pay the provider for any deductibles and copays, which are determined by your policy.
What Are the Different Types of Health Insurance?
When you shop for individual health insurance, talk directly with a licensed agent or do your own research online, you’ll find there are a number of different types of health insurance available.
Health Maintenance Organization (HMO)
Many people select a health maintenance organization (HMO). The primary reason is cost. Compared to other types of individual policies, HMOs are the most competitively priced. The reason is that you must receive care from providers that are “in-network,” meaning they’re on an approved list provided by the insurance company. If you’re fortunate, your doctor will be on that list, as well as the hospital that you prefer to go to.
The major drawback of an HMO comes when your doctor or hospital isn’t on the list of approved providers. This means that you’ll need to look over the list and select a new doctor, something many people are reluctant to do when they have a physician that they like and trust. For this reason, many people select a PPO when their doctor isn’t on the list of approved providers.
Providers in an HMO network get paid a fixed monthly amount for each plan participant who selects them as their primary care provider. Many newer doctors or those that don’t have established practices choose to participate in an HMO because doing so guarantees recurring monthly income, which grows as new members select them when enrolling in the plan.
Another drawback of an HMO is needing to have a referral from your primary care doctor when you need to see a specialist. For example, when you have recurring earaches and need to see an ear, nose, and throat specialist (ENT), you can’t make an appointment without seeing your primary doctor first, then getting a referral (permission) to see the ENT. This can delay you from getting the expert care you need in a timely manner.
Preferred Provider Organization (PPO)
Preferred provider organizations (PPOs) act much like HMOs in that you also have a list of providers to select from. Many more providers prefer to be on a PPO list and not an HMO list because of how they’re paid by the insurance company. There’s a much greater chance that your doctor will be on the list of providers for a PPO as well as for your preferred hospital.
PPOs are a bit more expensive than HMOs because the network is larger and PPOs pay the doctors in the network more when a claim is filed, unlike HMOs. HMOs pay doctors a flat fee each month for each member that selects them as their primary care physician.
A major reason many people choose a PPO plan is that no referral is needed to see a specialist. Using the example above, the person experiencing recurring earaches could pick up the phone or go online and make an appointment directly with the ENT specialist without getting a referral from a primary care doctor. This can reduce by days the amount of time needed to get the care you need to get a specialist.
Indemnity plan
An indemnity plan is a traditional health insurance plan that has deductibles and copays (described below). Many people select indemnity plans when they are looking for a high- deductible plan with lower premiums.
Medicare coverage
If you’re turning 65 or if you’re already there, you’ll want to be enrolled in the government-sponsored Medicare program. Medicare has several different parts, but the main parts are Part A and Part B.
- Part A is offered to you at no cost and covers your expenses if you are hospitalized.
- Part B covers doctor’s office visits and other miscellaneous medical expenses. You’ll pay $144.60 per month for Part B in 2020, and it increases slightly each year.
You can get supplemental Medicare expense policies available from private insurers that pay for some expenses not covered by Medicare. These policies also have monthly premiums, which vary from insurer to insurer. Shop for these policies when you enroll in Medicare for the first time, though they can be added later.
What Are the Key Features of Health Insurance Policies?
When you’re considering an individual health insurance policy, the features and benefits of the policy need to be carefully examined and understood so you don’t encounter any surprises when you’re at the doctor’s office and they’re waiting for payment.
Let’s look at some of the key features of the policies you’re evaluating.
Premium
The amount you pay each month to the insurance company for the protection it provides is called the premium. Premiums can be paid monthly, quarterly, semi-annually, or annually, but most people choose to pay monthly because they can budget more easily for the planned premium payment. Most people will also have the premium paid by direct debit out of their checking account by the insurance company for convenience.
Sometimes when an applicant has preexisting health conditions, the premium is “rated.” A rated premium is a percentage by which the premium is increased and is dependent upon the severity of the applicant’s underlying health condition. For example, someone with Type 2 diabetes may receive a premium rating of 125 percent, meaning he will pay 25 percent more than if he didn’t have diabetes.
Someone with a history of heart attacks may receive a premium rating of 175 percent, meaning he’ll need to pay 75 percent higher rates because of his health history. These ratings can sometimes make it cost-prohibitive for someone to obtain health insurance.
Deductible
The amount of money you have to personally pay out-of-pocket before the insurance company pays even a dollar in benefits is called the deductible. This amount can vary from $0 to $10,000 and it is an amount you select when you apply for a policy.
The higher the deductible, the lower the premium because you’re sharing a portion of the financial risk with the insurance company. HMOs normally have no deductible, while indemnity plans carry higher deductible amounts.
Most deductibles are calendar-year deductibles, meaning that once the first of the following year comes around, you’ll have to start over and pay your deductible once again for allowable charges. Some plans do feature a carryover deductible. It means expenses you incurred in the fourth quarter of a year will be applied against the next year’s deductible.
Copayment
A copayment (copay) is the amount you pay after you pay your deductible. It can be a percentage of the medical bill or a flat amount, depending on the type of plan you have.
For example, HMOs and PPOs have a flat copay amount. If you select an HMO or PPO, you normally have a very low copay when you see a primary care physician. They typically range from $5 to $25, depending upon whether you see your primary care physician or a specialist.
Indemnity plan copays are determined by a percentage of the medical bill and is paid by you after the plan’s deductible has been met. It usually ranges from 10 percent to 40 percent. Higher percentages equate to lower monthly premiums.
By selecting a higher percentage, you are assuming more risk for claims you may have, which lessens the insurance company’s risk and in turn, offers you lower premiums.
Maximum out-of-pocket amount
It’s important to know a policy’s out-of-pocket maximum amount before you select the best health insurance plan for you.
This amount is the highest amount you’ll need to pay in a given calendar year. Just like deductibles, the higher the dollar amount you select, the lower the monthly premium will be.
Preexisting condition provisions
Preexisting conditions are medical conditions you have before you apply for insurance. They can cause great difficulty for you when you are applying for individual health insurance. Depending upon the insurer and the state in which you’re applying for health insurance coverage, the insurance company can exclude certain medical conditions from being covered.
For example, if you have a medical history that includes treatment for kidney dialysis, an insurer may choose to offer you coverage with the provision that you’ll have no coverage for any claim related to your kidneys. This is upsetting to many people because these preexisting conditions are precisely the reason they’re applying for coverage.
How Do You Know if You Need an Individual or Supplemental Health Insurance Plan?
Few people would argue that everyone needs some type of health insurance, whether it be an individual or group policy. If you are not employed or work for an employer that doesn’t offer group health insurance coverage, you can apply for an individual health insurance policy.
There’s also supplemental health insurance coverage available, both to those who have health insurance and those who don’t. Companies like AFLAC (yes, the one with the duck commercial) offer supplemental plans. Would buying supplemental coverage be a good choice for you?
You might need a plan if...
- You don’t have health insurance coverage. Supplemental plans can offer you all types of coverage on an individual basis. They include hospital coverage, accident insurance, critical illness coverage, cancer plans, and more. The benefits aren’t as extensive as a true health insurance policy, but you can still avoid some major hospital bills by having this coverage.
- You are between jobs. While you are between one job and are waiting for another, supplemental plans can provide good basic coverage for you and your family.
- You have a family history of cancer. If cancer runs in your family, a supplemental cancer coverage plan can provide you extra protection if you get cancer. This policy will pay you benefits directly, which you can use to pay deductibles, copays, or make up for lost income while you’re sick.
- You have kids. Accident policies are great to have if you have active children. A compound fracture from a skateboard accident can cost you thousands of dollars. Premiums are very reasonable for accident policies that will cover events just like that.
You might not need a plan if...
- Your budget is tight: Adding up the premiums on all of the different types of supplemental plans can strain just about anyone’s budget. If you already have comprehensive individual or group coverage, this added expense may be something you can get along without.
- You have great coverage already: If you already have very good, comprehensive health insurance coverage, supplemental plans may be unnecessary. Most plans will pay for emergency room visits and just about every type of disease you’ll face.
How Do You Get Health Insurance Coverage?
There are several different ways that you can obtain your health insurance coverage.
Method 1: Your employer
You’re fortunate if your employer offers group health insurance. Most large companies do, but many small companies don’t because of the cost.
Just about every employer that offers coverage has you share in a portion of the cost, but your amount is almost always less than if you were to get coverage on your own.
Method 2: The Health Insurance Marketplace
This is a service that the federal government operates. It helps you shop for and enroll in affordable health insurance if you don’t have group coverage.
The Health Insurance Marketplace is available in most states, although some states provide their own state-run marketplace.
Method 3: Medicare or Medicaid
Medicare is a federal government program that provides health insurance coverage to all people over age 65 that meet the eligibility requirements. It provides coverage for hospitalization, doctor’s office visits, emergency care, medical devices, mental healthcare, and much more. There is a cost to the individual for certain segments of Medicare, including Medicare supplements that pay for medical expenses not covered by Medicare.
Medicaid is a federal and state program that helps with medical costs for some people with limited income and resources. It offers benefits not normally covered by Medicare, including nursing home care and certain personal care services. An application must be filed to qualify for Medicaid assistance.
Lower-income families may also qualify for the Children's Health Insurance Program (CHIP) or a free or low-cost county or city health program You can call 211 to connect with a relevant program or service.
Method 4: Get quotes online or through an agent
If you don't have coverage through work or federal or state programs, have a hard time navigating the Health Insurance Marketplace, or are looking for Medicare supplemental insurance, it might be worth comparing quotes through an online service or insurance agent.
You can get free quotes from a number of places, but we recommend using eHealth.
Get a Free Health Insurance Quote from eHealth
How Do You Pick an Individual or Supplemental Health Insurance Policy?
What separates one health insurance policy from another?
When evaluating insurers and insurance plans, price is almost always a major factor in the decision-making process. Health insurance is a big expense for most individuals and families and cost must be taken into account. But like anything, you do get what you pay for, so other factors need to be considered.
The quality and reputation of the insurance company is another important item to consider when choosing a policy. There are rating services you can check, like A.M. Best, Moody’s, and Standard and Poor’s, which can tell you much about the financial stability of insurance companies and their ability to pay claims in the future.
Also, the type of coverage you want will help determine the best health insurance company for you to enroll with. Do you prefer a low-cost HMO? Or a PPO with your doctor in its network? Or an indemnity plan with a high deductible? You need to pick a plan that gives you the peace of mind that the coverage will be there when you need it.
Popular Private Health Insurance Companies in the US
Here are some of the most popular health insurance companies in the U.S. and some information on what they have to offer. You'll likely run into these companies when comparing quotes on the Health Insurance Marketplace, or if you're comparing quotes online or with an agent.
It's important to remember that while you're shopping, compare both the policies and the companies, not just the company. A highly-rated health insurance company may offer a few less-than-stellar plans. Or a lower-rated company might offer the best plan in your area.
Kaiser Permanente
- Types of health insurance offered: PPO and HMO
- States available: Oregon, Washington, Virginia, Colorado, Georgia, California, Hawaii, District of Columbia, Maryland
- Offers online quotes? Yes
Kaiser Permanente plans work with employers, employees, and individual members to offer prepaid health insurance plans.
Blue Cross and Blue Shield
- Types of health insurance offered: HMO, PPO, indemnity
- States available: All 50 states
- Offers online quotes? Yes
There are 36 independent and locally operated Blue Cross and Blue Shield companies that offer health insurance coverage to one in three Americans.
Aetna
- Types of health insurance offered: HMO, PPO, indemnity
- States available: All 50 states
- Offers online quotes? Yes
Aetna offers many different types of health insurance, including Medicare and Medicaid plans. They also offer standalone pharmacy and dental plans.
Humana
- Types of health insurance offered: Medicare, prescription, dental, and vision
- States available: All 50 states
- Offers online quotes? Yes
Once known as one of the largest individual and group insurance providers in America, Humana has scaled back and as of 2018, no longer offers individual health insurance coverage. Humana specializes in Medicare plans and prescription drug coverage.
Cigna
- Types of health insurance offered: HMO, PPO, individual, and group
- States available: All 50 states
- Offers online quotes? No. Available through agent or broker.
One of the premier insurance providers in the U.S. Cigna is best known for its group insurance plans. They offer just about every type of health insurance plan available to groups, individuals, and seniors.
United Healthcare
- Types of health insurance offered: HMO, PPO, individual
- States available: All 50 states
- Offers online quotes? No. Available through agent or broker.
Based in Minnesota, United Healthcare is the largest healthcare company in the world by revenue — $242.2 billion in 2019. It employs 320,000 people and offers individual and group insurance.
Now that you're familiar with the different types insurance, the lingo, and popular companies, it might be time for you to get a quote. You compare from eHealth's individual or family plan's quote generator and choose the best policy for you and your family.
Get a Free Health Insurance Quote from eHealth
Buying Health Insurance: Frequently Asked Questions
You may have as many questions about health insurance as there are insurers. To help you find the best health insurance for you and your family, here are a few of the most frequently asked questions.
When does Open Enrollment typically take place every year?
Open enrollment typically starts in early November and ends in mid-December.
What can I do if I can’t afford health insurance?
If you can’t afford health insurance, you can look for hospitals and providers in your area that will give you reduced rates for paying cash when you receive treatment.
What happens if I don’t have health insurance and go to the hospital or get sick?
If you get sick or injured and need to go to the hospital without insurance you won’t be denied care or treatment.
How long do I usually have health insurance after losing a job?
You usually have health insurance until the end of the month in which you lose your job, as long as you were actively enrolled in a group plan and your premium had been paid.
Take Action
Now that you’re armed with a lot of useful information to find the best health insurance coverage, you can find coverage online or through a licensed insurance agent or broker.
You’re now able to speak the language you need to make a good choice and find the coverage you need at a cost you can afford.