Compiling...

Overview

Health Insurance

Having health insurance usually means you pay a premium every month and, in return, your health plan pays part of the bill when you need a service from a doctor or another provider to keep you healthy or treat a disease. Health insurance usually covers doctors' visits, prescription drugs, medical, and surgical services.

There are several different ways to get health insurance. Some people buy coverage on their own. Many people get coverage through their job or a family member's job. Others are covered through public programs like Medicare and Medicaid. State insurance regulators provide oversight for some of these types of health insurance. Different regulatory agencies have responsibility for other types of coverage. Explore the ways to get health coverage below:

Individual Market—Buying Health Insurance on Your Own

When you or your family purchase health insurance and are not part of a group that gets health coverage together (like an employer), you're considered to have 'individual market' coverage. Many people choose to buy individual market coverage through a health insurance marketplace, either Healthcare.gov or their state's marketplace. Buying through a marketplace allows those who qualify to get premium tax credits to help with the cost of their coverage. An insurance agent or broker can help you choose an individual market plan, or your state may have health insurance 'navigators' or other community-based assisters to help you.

While marketplaces only offer health insurance (and dental coverage) that meets certain requirements for benefits and coverage, other types of health insurance are also available to purchase on your own. These other types of insurance cover a more limited set of health care services and may choose not to cover you or charge you more if you have a pre-existing health condition. See a list of Other Types of Health Insurance below.

State insurance regulators help enforce consumer protections and other insurance laws for individual market insurance in their states. To find out how to contact your state's insurance commissioner, see the Members section.

Other Types of Health Insurance

Short-Term, Limited Duration Insurance

This insurance covers some of the same types of services as comprehensive health insurance, but is not required to offer a full set of essential health benefits. The plans typically cover a smaller share of the cost of services than comprehensive health insurance. That means you may pay less in premiums, but enrollees pay more when they need health care services. The plans may deny applicants or charge them more if they have pre-existing health conditions.

Basic Hospital Expense Coverage

This insurance covers a period of usually not less than 31 days of continuous in-hospital care and certain hospital outpatient services.

Basic Medical-Surgical Expense Coverage

This insurance covers costs associated with a necessary surgery, including a certain number of days of in-hospital care.

Hospital Confinement Indemnity Coverage

This insurance pays a fixed amount for each day that you are in a hospital.

Accident Only Coverage

This pays a lump sum when the enrollee experiences death, dismemberment, disability, or hospital and medical care caused by an accident.

Specified Disease Coverage

This insurance covers diagnosis and treatment of a specifically named disease or diseases, such as cancer.

Long-term Care Insurance

Long-term care insurance usually pays for skilled, intermediate and custodial care in a nursing home, as well as care in other settings, such as the home, adult day care center, or assisted living facility. The policy usually pays a fixed amount per day while a person is receiving care.

Other Limited Coverage

You may purchase insurance covering only dental or vision or other specified care.

Other Coverage That is Not Insurance

Health Care Sharing Ministries

Under these arrangements, members pay a monthly fee. When they have health care expenses, members can request that the ministry or other members share part of the cost. However, the ministry is not legally obligated to pay for members' health care costs. State insurance regulators generally do not provide oversight of health care sharing ministries.

Employer-based Coverage

Most nonelderly Americans get health care coverage through employment, either through their own job or a family member's. Employees and their families usually have a chance to sign up for coverage when starting a new job and once each year during an enrollment period.

State insurance regulators help to oversee insurance plans that employers purchase, often when the employer has fewer than 50 employees. But many employers choose to ‘self-insure' rather than purchase health insurance. The U.S. Department of Labor generally provides oversight of self-insured employer plans. Other agencies, including the Office of Personnel Management, the Defense Health Agency, and the Centers for Medicare and Medicaid Services, provide oversight when the employer is a government agency.

Public Coverage

Many people get health coverage through public programs like Medicare, Medicaid, and the Children's Health Insurance Program.

The federal Medicare program pays most medical expenses for people age 65 or older and for individuals under 65 receiving Social Security disability benefits. However, Medicare does not pay all expenses. As a result, some Medicare-eligible individuals choose to buy a Medigap policy that helps pay for certain expenses, including deductibles not covered by Medicare.

Medicaid and the Children's Health Insurance Program are administered by states. Here's a list of contacts for each state.

FAQ & Questions

Questions? We've got you covered.

What is Open Enrollment?

Each year there is a specified period when people can enroll in an individual market health plan. Consumers in most states use the federal marketplace through Healthcare.gov and, for them open enrollment runs Nov. 1 - Dec. 15. A few states either start open enrollment earlier or end it later. Consumers in California, Colorado, the District of Columbia, Massachusetts, Minnesota, New York and Rhode Island can use the links to check with their state marketplace and confirm dates.

Are there any changes for 2020?

There have been some updates regarding health insurance coverage—there will be no penalties for not having minimum coverage, short-term and limited duration options have been expanded, there are more direct enrollment options, and employer-based reimbursement arrangements are available to more employers. Read this Consumer Alert for more information.

Is there a penalty for not having minimum essential coverage?

In the past, consumers would pay a penalty with their federal taxes if they were not enrolled in a health plan. Starting Jan. 1, 2019, that federal tax penalty was reduced to nothing. However, some states have established their own penalties for going without insurance. If you don't have major medical health insurance, you'll be on your own for major health care costs and residents of some states may owe a penalty, but you won't be penalized with your federal taxes.

Does my Health insurance plan renew automatically?

Most health plans are required to offer you a renewal each year. It's your option to renew such plans but plans often renew automatically each year unless you take action to cancel. If you buy coverage on your own, there's a time each year called the Open Enrollment Period when you can select a new plan or renew the one you have. If you get coverage through your employer, there is usually a similar period for changing plans.

Can I opt out of a Health insurance plan?

Yes, you may opt out of an insurance plan. However, you should check with your health insurance provider to see if there is any penalty for cancelling your health insurance early.

You may not be able to enroll in another plan until the Open Enrollment Period, unless you qualify for a Special Enrollment Period. Check your policy first though, to see if there are any limitations on cancelling your plan. If you are not enrolled in any health plan, you’ll be on your own for major health expenses, but you won’t face a federal tax penalty. The federal tax penalty for not having coverage was reduced to nothing starting in 2019, but some states charge penalties when their residents go without coverage.

Can I have more than one Health insurance plan?

Yes, you may be enrolled in more than one plan. Some people are enrolled in employer-sponsored insurance as well as Medicare, or both Medicare and a Medicare supplemental plan. One plan will be considered primary and pay for your health claims. The other plan will be considered secondary and will process any remaining bills under its rules.

What is a Medigap policy?

A Medigap policy is health insurance sold by private insurance companies to fill the "gaps" in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan does not cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will each pay their share of covered health care costs.

What is Medicare supplemental coverage?

Medicare supplemental coverage is another way to refer to Medigap policies. The federal Medicare program pays most medical expenses for people 65 or older, or for individuals under 65 receiving Social Security disability benefits. However, Medicare does not pay all expenses. As a result, you may want to buy a Medigap policy, also known as Medicare supplemental coverage, that helps pay for certain expenses, including deductibles not covered by Medicare.

How do I know if I'm eligible for a Medigap policy?

To buy a Medigap policy, you generally must have Medicare Part A and Part B. You are guaranteed the right to buy a Medigap policy if you are in your Medigap open enrollment period or covered under a Medigap protection. You might not be able to buy a Medigap policy if you are in a Medicare Advantage Plan, have Medicaid, already have a Medigap policy, or are under the age of 65 and you are disabled or have End-Stage Renal Disease.

When should I apply for a Medigap policy?

When you elect coverage under Medicare Part B either due to age or disability, you have a 6-month open enrollment for a Medigap policy, which guarantees you coverage with a plan and company of your choice. You may choose from a list of standardized plans – listed as A through L (New enrollees cannot buy Plans C, F or F High Deductible after January 1, 2020. Find out more here.) If you do not purchase a plan within your 6-month open enrollment, any company you apply to can deny coverage based on your health conditions. There are some limited additional open enrollment periods available if you're unenrolling from a Medicare Advantage plan.

What isn’t covered in Medicare that is covered by Medigap?

You may want to buy a Medigap policy because Medicare does not pay for all your health care. There are “gaps” or “out-of-pocket” costs that you must pay in the Original Medicare Plan. Some examples of costs not covered are hospital stays, skilled nursing facility stays, blood, Medicare Part B yearly deductible and Medicare Part B covered services. A Medigap policy will not cover long-term care, vision or dental care, hearing aids and private-duty nursing.

What are my rights with Medigap?

Under Federal law, you have rights and protections regarding your Medigap coverage. These include your right to buy Medigap coverage, protections if you lose or drop your health care plan, and protections for people with Medicare under the age of 65. It is illegal for anyone to pressure you into buying a Medigap policy, lie or mislead you to switch to another company, or sell you a second Medigap policy when they know that you already have one. It is also illegal to sell you a policy that cannot be sold in your state. Call your State Health Insurance Assistance Program to better understand these rights and protections.

What are Medicare Advantage plans?

Medicare Advantage plans are private managed care plans that provide the standard Medicare benefits plus additional supplemental benefits for a monthly fee. These plans may include prescription drug coverage. Medicare Advantage participants may receive a subsidy for their prescription drug benefits in most cases.

What are Medicare Select plans?

Medicare Select plans are Medicare supplemental coverage plans that provide benefits through a network of providers similar to a Preferred Provider Organization (PPO). If the participant receives care from a provider under contract with the insurer, the cost will be lower.

What is COBRA?

Under COBRA, if you leave your current job you have the option to continue your health care coverage for up to 18 months. You are required to pay the full premium yourself, even if your employer paid part of your premium while you were employed, and the employer may charge an additional, limited administrative fee.

You can find out more about COBRA continuation of group health benefits from the Federal Department of Labor Office of Employee Benefits Security Administration website.

Shopping for health insurance?

Ask yourself these questions before you buy.

  • Why do you need health insurance?
  • Is the plan with the lowest premium really the most affordable?
  • Who are you buying health insurance for?
  • How long do you need health insurance – a full year or for a few months?
  • Do you have a known health condition (a pre-existing condition)?
  • What prescription drugs do you need?
  • Do you have any chronic health conditions, like high blood pressure, diabetes or an autoimmune disorder? Even if you haven’t been to a doctor, are you in pain or having problems you believe will result in any health care services or treatment?
  • Do you have a family doctor or hospital?
  • Are you ready to pay the full cost for services until a deductible is reached?
  • Are you able to pay the full cost for services if the plan limits how much it will pay?

Ask these questions if you receive a phone call about health insurance.

  • How did you get my information?
  • May I have your full name and contact information, please?
  • What is the exact name of your company and where are you located?
  • Is your company licensed? Are you a licensed insurance agent? If so, what’s your license number for (state)?
  • What’s the exact name of the insurance company on the policy and the name/type of policy I would be buying?
  • What’s your company’s phone number?
  • Will I need to pay a fee to join a group?
  • Please send a copy of the information to me through the mail.
  • Can I call you back after I’ve read your plan information?

Ask these questions about a plan you’re considering.

  • Is this a marketplace plan?
  • Does this plan cover the same benefits as a marketplace plan?
  • Does the plan cover pre-existing conditions?
  • What benefits doesn’t this plan cover, and what benefits have limits?
  • Where can I find out whether this plan covers my prescription drugs?
  • Where can I find the list of health care providers in this plan’s network?
  • What is the monthly premium I would pay for this plan?
  • What out-of-pocket costs will I have to pay when I need services?
  • What is the deductible?
  • Is there a maximum I would have to pay out- of-pocket?
  • Is there a limit on what the plan pays, per day, per year, or over my lifetime?
  • How long does this plan last?
  • Am I guaranteed the right to renew this plan?

Tips

Need help navigating health insurance?

Health Insurance Shopping Tool

NAIC’s Health Insurance Shopping Tool provides a 3-step process to compare different health insurance policies. Download and use the Health Insurance Shopping Tool to get a better look at how different policies measure up to your health care needs.

Consumers Guide to Medigap

Provides advice for consumers faced with the decision of whether to purchase Medicare supplement insurance. View the Consumers Guide to Medigap to get a better understanding of your options.

What to Ask When Shopping for Health Insurance

NAIC’s What to Ask When Shopping for Health Insurance helps you get the right information to choose the right health insurance policy for you. Download and use What to Ask When Shopping for Health Insurance to ask yourself and your agent question before purchasing.

More Help

Contact your state department of insurance to find out about other resources available in your state to help you understand and choose health insurance that’s right for you.

Be prepared before you buy.

Identify Your Current Healthcare Needs

Assess if you have any pre-existing conditions or will need specific doctors, services, or prescription drugs.

Look Closely for Changes

Don’t automatically renew the option you had before. If you buy a plan on your own, shopping on the marketplace each year gives you a chance to find a better deal. And many employers make changes from year to year, so it’s best to review your options.

Take Advantage of Wellness Incentives

Find out if your employer offers a wellness program that includes money-saving incentives for healthy behaviors such as exercising regularly or not smoking.

Tax-Free Savings

In addition to your health insurance coverage, you may be eligible to open a Flexible Spending Account (FSA) or a health savings account (HSA). And don’t forget about dependent care savings accounts.

Shop Around

Don’t make a decision or purchase a health plan after a single phone call or website visit. Compare policies and the financial help you may qualify for.

Check with Your State Insurance Department

Check with your state insurance department to make sure your agent and insurance company of interest are licensed within your state.

Monthly Premiums and Out of Pocket Costs

The premium is the amount you will pay each month to have coverage. Your out-of-pocket costs are what you’ll pay when you need health care services. A plan with a lower premium may come with higher out-of-pocket costs. Make sure to consider your total costs—both the monthly premium and what you’ll owe if you need services.

 

© 1991 - 2020 National Association of Insurance Commissioners. All rights reserved.
SM Insure U and Stop. Call. Confirm are registered service marks of the National Association of Insurance Commissioners.