Health insurance can help protect you and your family from unaffordable healthcare costs. And, under the Affordable Care Act, everyone must have health insurance or pay a penalty. Of course, this rule has some exceptions, which you can learn more about here. There are three main sources of coverage: your employer, individual plans and government programs (public insurance).
Through Your Job or a Family Member’s Job
Most people in the U.S. get health coverage through their jobs. In general, employers are required to offer insurance to full-time staff. You may also be covered through your spouse or parent if their employer provides family coverage, or, if you are a college student, through your school. Your employer may run their own “self-administered” plan, or buy a plan through an insurance carrier that they then offer to you. Some employers just offer one plan, while others give you a range to choose from, all with different benefits and costs. You may have the option of covering yourself or your whole family, or choosing between different plan types like HMOs, PPOs or high-deductible plans. Generally, you pay a monthly premium that comes out of your paycheck automatically, and your employer pays a portion as well. You will also usually have some out-of-pocket costs when you use your coverage, like deductibles, co-payments and co-insurance. If you work for a union that has agreements with more than one employer, you may be able to keep your coverage when you change jobs. If you just work for one employer, your coverage will end when you leave your job. You also may lose your insurance if you become a part-time employee. But, you may be eligible for COBRA continuation coverage, which allows you to stay in the plan for a time by paying the full cost of coverage yourself.
If you aren’t covered through your job or a family member’s job, you can buy coverage directly from an insurance company, or through special marketplaces set up through the Affordable Care Act.
Your own state may have a marketplace website, or you can visit the national marketplace at www.healthcare.gov. When you apply for coverage through the marketplace, you’ll answer a series of questions about your income, family size, and other factors to find plans near you, and determine if you are eligible for a tax subsidy to help pay your premium. Then, you will need to decide whether you want single or family coverage, and choose from a range of plans with different benefits and costs. Besides the monthly premium, you will usually have some out-of-pocket costs when you use your coverage, like deductibles, co-payments and co-insurance. Anyone may enroll in a health plan through the marketplace from November 1 to January 31. Some people may be eligible to enroll during other times of the year. In some cases, you can also buy a plan at other times of the year, for instance, if you lose your coverage because you leave your job or your work hours are reduced.
The marketplace offers four levels of plans. Each level is priced differently and covers a different amount of the cost of your care. “Bronze” plans have the lowest monthly premiums, but you will pay higher co-pays and deductibles when you need care. “Platinum” plans have the highest monthly premiums, but have low co-pays and deductibles. If you have a chronic condition, or need care regularly, you may want to choose a platinum-level plan to control your out-of-pocket costs. Or, if you are young and generally healthy, the low premiums of a bronze plan may outweigh the higher costs you’ll pay when you do occasionally visit the doctor. Some individuals, like young adults under 30 who are facing a financial or other hardship, may also be able to buy “catastrophic” plans. These plans have very low premiums, but the deductibles are extremely high. They are only meant to protect you in the case of a very serious accident or illness.
The chart below shows how much of the cost of your care you can expect to pay at each Marketplace plan level. This does not include your monthly premium. Keep in mind that this is an estimate of the total cost of your care over the year, not the amount for a specific service or treatment.
|Market Plan Level||Premium Cost||Your plan pays||
You pay (co-pays,
co-insurance, and deductibles
(not available to everyone)
|Less than 60%||More than 60%|
Sorting through all this information can be difficult, so many community-based organizations have trained “health insurance navigators” to guide people through their plan choices and help them enroll. You can find a navigator to help you in person or over the phone by visiting https://localhelp.healthcare.gov/.
There are government programs that offer affordable health coverage to the elderly, disabled and people who cannot pay for a plan.
Medicare covers the elderly and disabled. You become eligible for Medicare when you are 65 or older, or are permanently disabled and have been receiving a Social Security disability pension for two years. Medicare has several different “parts” that cover different services. You can visit any doctor or provider that accepts Medicare. If your income is low, you may be able to get help paying some Medicare costs. You can apply for Medicare online at www.socialsecurity.gov, or at your local Social Security office.
Medicaid covers people who cannot afford health insurance. States administer their own Medicaid programs, and eligibility, coverage and costs are different in each state. In some states, all adults below a certain income level are eligible. Your eligibility depends on factors like your age, income, your citizenship or immigration status, the number of people in your family, whether you are pregnant, and whether you have a disability. If you apply for coverage through Healthcare.gov, or your state’s health insurance marketplace, the site will automatically determine if you are eligible for Medicaid in your state. Most state programs have co-payments, co-insurance and deductibles, but they are very low. You can apply for Medicaid any time, and do not have to wait for an open enrollment period.
The Children’s Health Insurance Program (CHIP) covers children whose family income is too high to be eligible for Medicaid. Some state programs also cover parents and pregnant women. States administer their own CHIP programs, so eligibility, coverage and costs may be different from state to state. Most state programs have co-payments, co-insurance and deductibles,
but they are very low. You can apply for CHIP any time, even outside open
If you are covered by more than one plan
In some cases, you may be covered by more than one health plan. You might qualify for both Medicare and Medicaid, or you and your spouse may both have family coverage through your employers. In that case, the two plans will “coordinate” the payments for your care. Make sure to show both your health insurance ID cards when you visit the doctor or get care.
Please keep in mind that the medical and dental reimbursement cost estimates that you receive from the FAIR Health consumer website are relevant for private health plans, not public insurance plans.
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