What Do I Need to Know About Individual Health Insurance?

by Holley Maher

Individual health insurance is different from group health insurance, and there are many things to know and understand. Let’s start with the basics so you can be confident in and educated about your purchase.  

• When can I purchase individual health insurance? Open enrollment is from Nov. 15, 2014, to Feb. 15, 2015.
• Can I purchase health insurance outside open enrollment? To buy insurance outside open enrollment, you must qualify for a “qualifying life event,” such as marriage, birth of a child, adoption of a child, or loss of coverage.
• What happens if I do not purchase health insurance? If you don’t have health coverage during 2015, you may have to pay a fee. The fee in 2015 is 2% of your income, or $325 per adult/$162.50 per child, whichever is more.
• When I apply, do I have to answer medical questions? Individual health plans will no longer require the applicant to disclose pre-existing conditions.   

If you plan to shop for health insurance coverage during the open enrollment period, it is important to answer the following questions before meeting with a trusted insurance adviser:

1. Does your employer or your spouse’s employer contribute toward your health insurance?
2. What is your household’s modified adjusted income?  
3. Are any of the following relevant to your circumstances: Disabled? Veteran? Pregnant? Have children? Over 65 years of age?  
4. Do you want the insurance to cover major medical expenses? Routine expenses? Simply satisfy the Affordable Care Act requirement so you do not pay a penalty?
5. What amount of money are you able to spend monthly, or annually, on your health insurance?
6. Do you have an established relationship with one or more doctors that you do not want to change? Do you visit doctors or hospitals in another state?

Once you have identified the answers and determined your objectives, it is time to apply.  Consumers should explore both public and private options through brokers, healthcare.gov, medicare.gov, or web-based entities (WBE). The guide below will help you assess a few enrollment resources:

Insurance brokers: For years, brokers have advised consumers on health insurance options; however, every broker is not created equal. Before you purchase coverage through a broker, you should ask: With which states and insurance companies is the agent licensed? Is the agent licensed to sell plans on healthcare.gov or medicare.gov? Does the broker know and understand my needs and advise appropriately?

Medicare.gov: This site allows eligible consumers to learn about Medicare options, shop for plans and apply. Some brokers are licensed to sell Medicare supplement plans and can assist with this process.

Healthcare.gov: At healthcare.gov, individuals complete one application that is used to determine eligibility for government subsidies, Medicaid or the Children’s Health Insurance Program (CHIP). Navigators, application assisters and licensed brokers can help individuals complete the application process through healthcare.gov.

Web-based entities (WBEs): Not all insurance carriers offer products on healthcare.gov. This is where a WBE can be useful. Through a WBE, consumers have access to all the same plans and prices offered through healthcare.gov plus all the plans in the private market. As a result, a WBE will present to you the broadest array of options. WBEs are offered only through entities and brokers who have received approval by the Centers for Medicare and Medicaid Services (CMS). An example of a WBE is found at www.smartbenefitsindividuals.com.

Health insurance can be confusing and costly. The most important thing is to identify your priorities so you can engage a resource who has the licensing and knowledge to help you meet your objectives. n

Holley Maher (hmaher@SmartBenefitsPlus.com) is a Partner at Maher, Rosenheim, Comfort and Tabash LLC, specializing in group benefits.