Consider your and your family’s health care needs. Make sure any plans you choose cover your preferred doctors and pharmacies. Eliminate any programs that don’t have local in-network providers. Remember that your household size and income determine what plans are available, how much you pay for them, and whether you qualify for premium tax credits to help reduce costs on the Marketplace.
Employer-Sponsored Coverage
Companies offer employer-sponsored coverage as a benefit for employees and their dependents. It is the most common way Americans get major medical coverage. Typically, it comes with a company’s choice of health insurance plan, and employers pay all or a portion of the monthly premium. It also allows workers to make pre-tax contributions toward their insurance costs.
Most big companies offer group health insurance, and they are required to do so by law. Under the Affordable Care Act or Obamacare, large employers must submit an affordable plan that meets minimum value standards. These standards require the plan to cover, on average, 60 percent of an employee’s healthcare expenses and to cost less than 9.78 percent of their income.
Smaller businesses that do not offer insurance have informal strategies to help their employees with healthcare needs. One option is to give workers a salary bonus to purchase individual health insurance plans. A health reimbursement agreement, or HRA, is what it is known as. The tax rules around this arrangement vary from state to state, and only C-corporations can fully participate in an HRA. While employer-sponsored coverage is the most popular and widely available healthcare coverage, only some get it. If a worker cannot access an employer-sponsored health insurance plan or cannot afford it, they can look into the state marketplaces or private exchanges. They can also consider a short-term plan to fill the gap until they can enroll in an employer-sponsored plan.
Individual/Family Coverage
Families and individuals without access to an employer-sponsored plan or eligibility for a government program have access to health insurance choices. Individual plans are available through private insurers and the health insurance marketplace. A family plan is similar to a personal plan except that it covers two or more people. Family coverage tends to cost more than an individual plan. It is because a family plan typically has a higher deductible and out-of-pocket maximum. Many states have expanded Medicaid to provide coverage for low-income individuals and families.
Additionally, other programs, like the Children’s Health Insurance Program (CHIP), offer coverage for children who do not have a parent with health insurance or who cannot afford private coverage. Many of these options have varying enrollment periods; some need to learn how to get low cost health insurance. There are online websites that could help you get one. It is important to review your options carefully and make sure that you enroll during the correct period. If you miss open enrollment for the year, you may have to wait until the next period or pay a penalty for not having coverage.
Medicare
If you or your spouse worked for the federal government for at least ten years, you may qualify for premium-free Medicare Part A coverage. You can also buy Medicare Parts B and D, which will require a monthly premium (taken from your Social Security or personal check) and may include deductibles and co-payments. Private companies sell Medicare supplemental insurance policies, or Medigap plans, which help pay some of the costs that Medicare does not cover, like co-payments, coinsurance, and deductibles. These plans vary by price, network size, and choice of doctors, pharmacies, and specialists.
Individuals who miss the opportunity to enroll in Part B or premium Part A during their initial enrollment period, because they performed volunteer service outside the United States for at least 12 months on behalf of a tax-exempt organization may use an Exceptional Circumstances SEP. This SEP begins the month after an individual notifies the Social Security Administration of their service and ends six months later. If individuals choose to have their Medicare benefits start retroactively, they will be responsible for paying back any corresponding premiums. If you do not qualify for a special enrollment period, you can purchase health coverage through the Marketplace or your state’s health exchange program anytime during the year.
Medicaid
If you have a modest income, Medicaid might be able to provide you with free or inexpensive health insurance. Health care services are covered through a combined state and federal program for those with extremely low incomes. Each state runs its own Medicaid program with guidelines from the federal government, but most follow similar rules and requirements for eligibility. Most states offer Medicaid for children, parents, adults without a disability who meet certain income levels, and individuals 65 and older who meet specific income requirements. Some states have expanded their Medicaid programs to include adults with very low incomes. Check with your local Department of Social Services (LDSS) or the Medicaid agency in your state to see if you are eligible for Medicaid.
Individuals can also purchase private health insurance directly from a health insurance company. These plans are available through the ACA marketplaces and outside the marketplaces. Private health insurance is usually more expensive than Medicaid but can cover more costs like deductibles and co-payments. You can have both Medicaid and private health insurance simultaneously if you are eligible for both. If your family’s situation changes, updating your application is important to get the best coverage possible. For example, if you are moving, having a baby or losing your job, apply for new coverage as soon as possible.
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