Health Insurance

Types of Individual Health Insurance Plans

On the Marketplace & Off the Marketplace   (We can help you determine what your best route is)

Who buys individual health insurance?

About 6 percent of people under age 65 are covered by an individual (or non-group) health plan. The individual health insurance market is sometimes referred to as a residual market.  This is where people go to buy health insurance when they don’t qualify for insurance under a group health plan, or when they aren’t eligible for a public program such as Medicare or Medicaid .

Even though it isn’t a large percentage of the overall market, people often need individual health insurance for themselves or their families when they work in jobs that don’t offer health benefits, are between jobs, or when they are self- employed even if only for a period of time. In addition, people who retire before the age of 65 (when Medicare eligibility starts) may need individual health insurance. People who are divorced or widowed can end up in the individual insurance market, as do some young adults when they first become too old to be on their parents’ policies.

What does individual health insurance cost?

The cost of individual health insurance currently varies enormously, depending on what the policy covers; the age, gender, and health status of the person buying it; and geographic location in which it is sold, among other things. Beginning in 2014, health plans will no longer be allowed to charge higher premiums based on gender or health status. The only factors by which health plans will be able to vary premiums will be age, tobacco use, family size, and geographic area.

What does individual health insurance cover?

Ten Essential Health Benefits must be offered at no dollar limits on every plan under the Affordable Care Act (ObamaCare). Essential Health Benefits consist of ten categories of items and services required on all individual and small group plans starting in 2014. Large Group Plans are not required to offer an essential benefits package, but most already do, as these benefits were defined from the coverage typically provided by large employers.

In general, Essential Health Benefits are the types of care you need to prevent and treat sickness and do not include elective and “non-essential treatments”. A full list of Essential Benefits under the Affordable Care Act with descriptions is provided below.

All plans sold on and off the Health Insurance Marketplace, small group plans, and Government healthcare options like Medicaid and Medicare starting January 1st, 2014 or later will offer at least ten Essential Benefits regardless of cost.

The Affordable Care Act’s Ten Essential health benefits include:

1. Ambulatory patient services (Outpatient care). Care you receive without being admitted to a hospital, such as at a doctor’s office, clinic or same-day (“outpatient”) surgery center. Also included in this category are home health services and hospice care (note: some plans may limit coverage to no more than 45 days).
2. Emergency Services (Trips to the emergency room). Care you receive for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness. Typically, this is a trip to the emergency room, and includes transport by ambulance. You cannot be penalized for going out-of-network or for not having prior authorization.
3. Hospitalization (Treatment in the hospital for inpatient care). Care you receive as a hospital patient, including care from doctors, nurses and other hospital staff, laboratory and other tests, medications you receive during your hospital stay, and room and board. Hospitalization coverage also includes surgeries, transplants and care received in a skilled nursing facility, such as a nursing home that specializes in the care of the elderly (note: some plans may limit skilled nursing facility coverage to no more than 45 days).
4. Maternity and newborn care. Care that women receive during pregnancy (prenatal care), throughout labor, delivery and post-delivery, and care for newborn babies.
5. Mental health services and addiction treatment. Inpatient and outpatient care provided to evaluate, diagnose and treat a mental health condition or substance abuse disorder . This includes behavioral health treatment, counseling, and psychotherapy. (note: some plans may limit coverage to 20 days each year. Limits must comply with state or federal parity laws. Read this document for more information on mental health benefits and the Affordable Care Act).
6. Prescription drugs. Medications that are prescribed by a doctor to treat an illness or condition. Examples include prescription antibiotics to treat an infection or medication used to treat an ongoing condition, such as high cholesterol. At least one prescription drug must be covered for each category and classification of federally approved drugs, however limitations do apply. Some prescription drugs can be excluded. “Over the counter” drugs are usually not covered even if a doctor writes you a prescription for them. Insurers may limit drugs they will cover, covering only generic versions of drugs where generics are available. Some medicines are excluded where a cheaper equally effective medicine is available, or the insurer may impose “Step” requirements (expensive drugs can only be prescribed if doctor has tried a cheaper alternative and found that it was not effective). Some expensive drugs will need special approval. 
7. Rehabilitative services and devices – Rehabilitative services (help recovering skills, like speech therapy after a stroke) and habilitative services (help developing skills, like speech therapy for children) and devices to help you gain or recover mental and physical skills lost to injury, disability or a chronic condition (this also includes devices needed for “habilitative reasons”). Plans have to provide 30 visits each year for either physical or occupational therapy, or visits to the chiropractor. Plans must also cover 30 visits for speech therapy as well as 30 visits for cardiac or pulmonary rehab.
8.  Laboratory services. Testing provided to help a doctor diagnose an injury, illness or condition, or to monitor the effectiveness of a particular treatment. Some preventive screenings, such as breast cancer screenings and prostrate exams, are provided free of charge.
9. Preventive services, wellness services, and chronic disease treatment. This includes counseling, preventive care, such as physicals, immunizations and screenings, like cancer screenings, designed to prevent or detect certain medical conditions. Also, care for chronic conditions, such as asthma and diabetes.
10. Pediatric services. Care provided to infants and children, including well-child visits and recommended vaccines and immunizations. Dental and vision care must be offered to children younger than age 19. This includes two routine dental exams, an eye exam and corrective lenses each year.

What is ‘long-term care’?
Because of old age, mental or physical illness, or injury, some people find themselves in need of help with eating, bathing, dressing, toileting or continence, and/or transferring (e.g., getting out of a chair or out of bed). These six actions are called Activities of Daily Living–sometimes referred to as ADLs. In general, if you can’t do two or more of these activities, or if you have a cognitive impairment, you are said to need “long-term care.”

Long-term care isn’t a very helpful name for this type of situation because, for one thing, it might not last for a long time. Some people who need ADL services might need them only for a few months or less.

Many people think that long-term care is provided exclusively in a nursing home. It can be, but it can also be provided in an adult day care center, an assisted living facility, or at home.

Assistance with ADLs, called “custodial care,” may be provided in the same place as (and therefore is sometimes confused with) “skilled care.” Skilled care means medical, nursing, or rehabilitative services, including help taking medicine, undergoing testing (e.g. blood pressure), or other similar services. This distinction is important because generally Medicare and most private health insurance pays only for skilled care–not custodial care.

What are the types of disability insurance?
There are two types of disability policies: Short-Term Disability (STD) and Long-Term Disability (LTD):

1. Short-Term Disability policies (STD) have a waiting period of 0 to 14 days with a maximum benefit period of no longer than two years.
2. Long-Term Disability policies (LTD) have a waiting period of several weeks to several months with a maximum benefit period ranging from a few years to the rest of your life.

Disability policies have two different protection features that are important to understand.

1. Non-cancelable means the policy cannot be canceled by the insurance company, except for nonpayment of premiums. This gives you the right to renew the policy every year without an increase in the premium or a reduction in benefits.
2. Guaranteed renewable gives you the right to renew the policy with the same benefits and not have the policy canceled by the company. However, your insurer has the right to increase your premiums as long as it does so for all other policyholders in the same rating class as you.

In addition to the traditional disability policies, there are several options you should consider when purchasing a policy:

• Additional purchase options
  Your insurance company gives you the right to buy additional insurance at a later time for an additional cost.
• Coordination of benefits
  The amount of benefits you receive from your insurance company is dependent on other benefits you receive because of your disability. Your policy specifies a target amount you will receive from all the policies combined, so this policy will make up the difference not paid by other policies.
• Cost of living adjustment (COLA)
  The COLA increases your disability benefits over time based on the increased cost of living measured by the Consumer Price Index. You will pay a higher premium if you select the COLA.
• Residual or partial disability rider
  This provision allows you to return to work part-time, collect part of your salary and receive a partial disability payment if you are still partially disabled.
• Return of premium
  This provision requires the insurance company to refund part of your premium if no claims are made for a specific period of time declared in the policy.
• Waiver of premium provision
  This clause means that you do not have to pay premiums on the policy after you’re disabled for 90 days.