- Health insurance is not easy to navigate, but most Americans can’t afford the cost of medical care without it.
- About 58 million people over 65 are insured, in part, through Medicare, while nearly half of Americans get private health insurance through an employer.
- Those not covered by an employer or Medicare can get private health insurance through HealthCare.gov, where they may qualify for tax credits.
- The Marketplace’s open enrollment period for 2020 health coverage runs from November 1, 2019 to December 15, 2019.
- You can also shop for private health insurance off the government-run Health Insurance Marketplace, directly through a health insurer, on private marketplaces, or through a broker.
- Visit Business Insider’s homepage for more stories.
Health insurance is not easy to navigate, even for experts.
But most Americans need insurance to afford healthcare. Choosing the plan that’s right for you may take some research, but it serves as your first line of defence against medical debt, one of biggest sources of debt among consumers in the US.
Here’s how to start:
How to get health insurance
1. Find a job with healthcare coverage
While folks over 65 qualify for Medicare, the government’s health insurance program, Americans under age 65 are responsible for obtaining their own health insurance. However, adults can remain on their parents’ policy until age 26.
Some 158 million Americans get their health coverage through their employer or a spouse’s employer, according to the Commonwealth Fund. Employees who are eligible for coverage through work usually don’t need supplemental health insurance.
The human resources team at your company can walk you through exactly what your plan offers and how much you’ll be expected to pay for premiums, deductibles, coinsurance, and copayments. Your plan may also offer vision and dental coverage at an extra cost.
Some companies, including Whole Foods, Starbucks, and Costco, offer full health insurance benefits for part-time employees as well.
2. If you recently left a full-time job with health coverage, consider COBRA
If you recently left a full-time job where you had health insurance, you can opt to continue coverage until you find a new plan.
Named for the Consolidated Omnibus Budget Reconciliation Act of 1985, COBRA allows a person to continue receiving the exact same health coverage they have been getting from their employer after they leave. It’s offered by most employers with 20 or more employees.
While COBRA enables a former employee to retain coverage at group insurance rates, the individual is often required to pay both the employer and the employee’s portion, plus an administrative fee, driving up costs significantly.
An individual usually has 60 days to elect to receive coverage under COBRA after leaving their employer. Coverage can last between 18 and 36 months, depending on the nature of the “qualifying event,” or the reason for leaving.
3. Find out whether you qualify for Medicaid
Medicaid is the government’s health insurance program for Americans who are low-income, have children, are pregnant, or are disabled. Depending on how you apply for Medicaid, the requirements to qualify can be complicated, and depend a lot on where you live.
You may qualify for Medicaid if your income is under 138% of the federal poverty level and you live in one of the 37 states that expanded eligibility for Medicaid. The 2019 income limit for a four-person household is $US34,638 this year in every state except Hawaii and Alaska, which have higher guidelines.
Other states have different income limits and eligibility criteria. Find out if you qualify for Medicaid, or other income-based subsidies, at HealthCare.gov.
4. Browse the Health Insurance Marketplace for private insurance options
Established by the Affordable Care Act, the Health Insurance Marketplace is a resource available to most US citizens and can help narrow down private health insurance coverage options, and find out whether tax breaks or other subsidies are available. Eleven states and Washington, DC use their own health insurance marketplace, which you can find here.
Notably, insurance offered through the Marketplace cannot deny any individual coverage, even for pre-existing conditions. According to Policygenius, these plans all minimally cover the 10 essential benefits mandated by the federal government, including emergency services and pregnancy and newborn care, plus any benefits required by your state of residence. Some also include dental coverage.
First you have to fill out an application with your estimated income for the year and information about your spouse and/or dependents (here’s a handy checklist). This will generate a list of the health plans available to you.
When comparing plans, you’ll want to look at premium costs, per individual and per family deductibles, copayments, hospital costs, and coverage details, like whether extra costs are levied to visit out-of-network providers.
To get a sense of how much you could wind up paying in a worst-case scenario, a quick trick is to add up your total annual premium and the maximum out-of-pocket limit of your insurance choices, suggests Business Insider’s healthcare editor Zachary Tracer.
The Marketplace’s open enrollment period for 2020 health coverage runs from November 1, 2019 to December 15, 2019. However, losing job-based coverage, getting married, or having a baby at any point during the year may qualify you for a special enrollment period.
5. Understand the metal tiers
Plans on the Marketplace are offered at four price tiers: bronze, silver, gold, and platinum. An estimated ratio of what the insurer pays versus what the individual pays is the distinguishing factor between the levels, Policygenius explains.
Only copayments, coinsurance, and the deductible are taken into account to determine which tier the plan is (monthly premiums are not included). The individual is responsible for the highest share of the cost in a bronze plan (40%), though the insurer still takes on the majority (60%), and the lowest share of the cost in a platinum plan (10% vs. the insurer’s 90%).
As such, monthly premiums usually correlate to the tiers – bronze plans have the lowest premiums, while platinum plans often have the highest premiums, and silver and gold fall somewhere in between, according to Policygenius. Importantly, this does not indicate the quality of the healthcare a person will receive under the plan.
6. Understand the types of health insurance
Health insurance plans are also categorised by network coverage. Here are the five main types:
- Health Maintenance Organisation (HMO): “The most restrictive plan,” according to Policygenius, which requires you to choose an in-network primary care physician and obtain a referral to see a specialist. These plans do not cover any out-of-network costs.
- Preferred Provider Organisation (PPO): “The least restrictive plan,” according to Policygenius, which gives you the option to see an out-of-network provider for a higher cost. These do not require a referral to see a specialist, but do usually come with higher premiums.
- Exclusive Provider Organisation (EPO): A hybrid plan which does not require a referral for out-of-network specialists and does not cover costs.
- Point of Service (POS): Another hybrid plan which requires an in-network primary care physician, but allows out-of-network options at a higher cost. It also requires a referral for specialists.
- High deductible health plan (HDHP): These plans typically have low or no premiums, but require the individual meet a high deductible or out-of-pocket maximum before insurance coverage kicks in. They also come with a health savings account (HSA), a powerful, triple tax savings investment tool.
7. Compare private insurance plans off the government-run marketplace
You can also shop for private health insurance off the Marketplace. These are plans sold directly by the health insurer, through a privately-run health insurance marketplace, or through a third-party broker like Policygenius.
While these plans still abide by the rules outlined in the Affordable Care Act – they must cover the 10 essential benefits, at least – they’re ineligible for any tax credits or subsidies from the government, even if your income qualifies. They may or may not have the same metal tier designations (bronze, silver, gold, platinum) as the plans listed on the Marketplace.
Despite not allowing tax breaks, the policies not offered on the Marketplace may be cheaper and/or better suited for your situation.
8. Consider a health-sharing plan
Health-sharing ministries are an alternative to run-of-the-mill health insurance. These non-profit organisations are funded by monthly premiums, called the sharing amount, paid by the members and require a deductible-like amount to be met before coverage kicks in.
While not considered health insurance coverage under the Affordable Care Act, individuals belonging to health-sharing ministries before 2019 were exempt from the “Shared Responsibility Payment,” or the fee mandated for not having health insurance. Health-sharing ministries, however, operate on the good will of others – they’re largely voluntary and recourse isn’t guaranteed.
These organisations are generally faith-based and require that members follow guidelines, such as no tobacco use and regular worship, in lieu of a standard evaluation based on gender, age, weight, and other health factors. As with anything, understand the fine print before signing on.
Correction: A previous version of this article stated that health-sharing ministries do meet the standards outlined in the Affordable Care Act for qualifying health insurance. They do not meet the standards for insurance under ACA, however, there is no longer a “Shared Responsibility Payment,” or penalty, for individuals without health insurance beginning in the 2019 plan year.