Individual and Family Health Insurance

What are family and individual health insurance plans?
Individual and family health insurance plans ensure that all members can access the medical care they need. The health insurance rates on these plans are low and affordable, and the plans offer great coverage, meaning there is no reason why you and your family should go unprotected. An individual health plan can help you if you do not have health insurance through your job or if you are looking for health plans and are self-employed. Family health insurance plans can cover your whole family, including your spouse and any children you may have.
What types of individual and family health insurance plans can I obtain?
There are two types of family and individual health insurance plans. These are “managed-care” plans and “indemnity” plans. There are a few differences in these individual health plans. The biggest difference comes in the up-front costs, as healthcare insurance providers will bill things differently. In most cases, a managed-care plan will have fewer providers than an indemnity plan. However, with an indemnity plan, the healthcare insurance provider will only pay for your medical coverage after they receive your bill, and there may be some upfront charges for which you will initially pay. You will then wait to receive reimbursement for these charges. If you choose a managed care plan from your healthcare insurance provider, you will also need to know that there are multiple types. HMOs, POS, and PPO plans are all considered to be managed care plans that require you to use the healthcare insurance provider’s network. On these plans, the services that you receive have pre-determined prices, and the network submits your bills to the health insurance companies for you. This equals fewer costs upfront for you to pay, though you will be limited to what providers you can see.
What are PPO health plans?
With a PPO health plan, also known as a preferred provider organization plan, your private health insurance provider will give you a network of doctors and hospitals that are preferred by the company. If your doctor or hospital is a part of this network, you will receive discounted rates. In most cases, your health insurance provider will not require you to choose a primary care physician; instead, you are free to see anyone in the network. With some individual health plans, you will have an annual deductible that will have to be met before the insurance company begins paying. You may also have copayments or other payment requirements to be met on your family health insurance plans before coverage will begin. If you see a doctor that is not a part of your health insurance provider’s network, you will generally have to pay more.
What are HMO health plans?
An HMO health plan, also known as a health maintenance organization, is an individual health plan that exchanges the number of available doctors and hospitals for lower upfront costs. A person with medical insurance with an HMO will have to pay less up front, but will have fewer doctors to choose from when they need care. These family health insurance plans require you to choose a primary care physician who will oversee the majority of your medical care. If you need to see a specialist or a different physician, you will need a referral to ensure that your health insurance provider will cover the costs. With an HMO, you receive a large range of preventative health care services. The health insurance provider also does not typically require a deductible, and any copayments are generally small. While on this individual health plan, you will only be able to see doctors and hospitals that are in the network.
What are POS health plans?
A POS Plan, also known as a point of service plan, is a type of individual health insurance plan that is a combination of an HMO and a PPO plan. If you choose this type of individual health plan, you will need to designate a primary care physician, just as you would with an HMO plan. If you would like to see a doctor or visit a hospital that is outside of the network, you would need a referral to ensure that you receive the appropriate health insurance rates. In most cases, this family health insurance plan will not have a deductible, and the health insurance rates on copayments are low and affordable. Like a PPO plan, you can choose to see a doctor out of your network; however, there may be higher deductibles and upfront costs to do so. You will also be required to submit your own medical claims to your health insurance provider if you see a doctor that is not in your network.
Is there a difference between physicians that are in-network versus those that are out-of-network?
If your private health insurance plan has a network, then there is a large cost difference between doctors that are in the network and who that are not. Physicians that are in the network have a contract with the health insurance provider to provide their services at a set price. In most cases, for services covered under your family health plan, you will only have to pay any copayments and/or deductibles. However, a doctor that is not in your network does not have this same contract with the health insurance provider. Because of this, many health insurances companies will not pay for you to see an out-of-network provider, or they will only pay a portion of the bill. An Indemnity plan usually does not have a network, and you can see whichever doctor you choose, but HMO, PPO, and POS plans generally have networked providers. Depending on your individual health insurance plan, you may have a wide selection of healthcare providers to choose from, or you may only have a limited list.
Should I put my spouse and children on my work’s group plan?
Yes and no. YES if your spouse or a child has a serious or chronic condition that has been treated or diagnosed. Serious, chronic and pre-existing conditions can sometimes be denied by insurance companies offering individual and family plans, but by law must be covered under employer group plans. NO if you want the similar benefits for a lot less money. For most of you, health insurance companies will consider you and your children healthy. On your employer’s plan, which is required by law to cover all healthy and unhealthy people, you will pay more for the same benefits because you, as a healthy person, must pay to help offset the costs of the unhealthy people. Whereas on an individual or family plan, you only pay for you and your family ““ often saving a lot of money. Sometimes saving up to 50% per month. NO if you want to ensure your family always has the health insurance they need. With employer-based insurance, your family loses that insurance when you leave that company. And if anyone has been treated for a serious illness, then that can be problematic when trying to get health insurance on your own. However, once your family is on an individual or family plan, they will always have the health insurance coverage they need no matter where your career takes you. Provided you keep the insurance in force, that is.
Can I get individual or family health insurance if I have a Pre-Existing Condition?
Yes, you are eligible for individual health insurance even with a pre-existing condition. However, there are several options available to health insurance companies when they look at someone with a pre-existing condition. One, they can deny coverage outright. That is, if they look at your pre-existing condition and determine that it is too severe to insure, they may decline offering you coverage. This is a risky position for you to be in because once one health insurance company has denied you, then most of the others are likely to follow suit. If you think you have a pre-existing condition, please seek several resources before applying for a plan. Two, they can issue a Condition Specific Deductible. This is something where they grant you full health insurance coverage on everything except the specific pre-existing condition. For that, they provide a separate deductible limit, almost always considerably higher than a typical deductible, to minimize their risk on that specific condition. Three, they can exclude that condition specifically. That is, an insurance company may offer you full health insurance except on that specific pre-existing condition that they decline to cover at all. Four, they can choose what is called “rating” your plan. This is when an insurer will increase the price of your plan by a certain percentage to cover their potential costs of covering the condition. For example, if your plan costs $100 per month and is “rated” up 25% based on a specific pre-existing condition, then you would end up paying $125 per month for the same benefits.
What if I can’t afford health insurance?
Family budgets can become tight. We certainly understand this. Our own family budgets can get tight. And for some families, the simple reality is they can’t afford health insurance. If you feel that you and your family fall into this situation, please contact your state Medicaid office to see if you are eligible for help. However, if you are like most of us, you may not think you can afford health insurance, but the truth is private health insurance can be remarkably affordable. In most states, individual and family plans can cost up to 50% less than plans you can get through your employer with similar benefits. And, you can’t afford NOT to have health insurance. It’s one of those truths that we don’t necessarily like and we certainly understand how it comes across when we say it. We sell health insurance and we’re telling you that you have to have it. Predictable, right? Pathetic, right? But true. It’s not a question of having it for the sake of having it. It’s natural to question its worth when we think we’re healthy. But at some point in life we all get sick. And at that point, we all deserve to see the best doctors at the best facilities in the world. And that only happens when we have health insurance. Problem is that when we don’t have health insurance and we get sick, at that point it’s too late. And if the illness is serious and ongoing, it may be very tough to ever get treatment for that illness that otherwise would have been covered by health insurance. Please don’t make the mistake of thinking that situations like that happen to other people. At some point, it will affect you or a member of your family. Please take care of yourself.
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