Getting Health Insurance for Yourself: Your Options

Quick answer

• You can get health insurance through your employer, the Health Insurance Marketplace, Medicare, Medicaid, or by purchasing a private plan.
• Your eligibility for certain options depends on factors like your employment status, income, and age.
• The Health Insurance Marketplace offers plans with potential financial assistance based on your income.
• Understanding your coverage needs and budget is crucial before choosing a plan.
• Always compare different plans and providers to find the best fit for your situation.

What to check first (before you buy or change coverage)

Coverage needs

Before you even look at plans, think about your health. Do you have any pre-existing conditions? Do you regularly see specialists or take prescription medications? Consider how often you visit the doctor and what types of care you anticipate needing in the coming year. For example, if you’re planning a family, you’ll need to factor in maternity care. If you have a chronic illness, you’ll want a plan that covers your ongoing treatments and medications comprehensively.

Deductibles and premiums

These are two of the most significant cost factors in health insurance. Your premium is the monthly amount you pay to have insurance. Your deductible is the amount you pay out-of-pocket for covered healthcare services before your insurance plan starts to pay. A plan with a lower premium often has a higher deductible, and vice-versa. Consider your financial situation and how much you can afford to pay monthly versus how much you could afford to pay if you needed significant medical care.

Exclusions and limits (general)

Every health insurance plan has specific services it won’t cover (exclusions) and limits on how much it will pay for certain services. Common exclusions might include cosmetic surgery or experimental treatments. Limits can apply to the number of physical therapy visits or the amount spent on certain types of care. Carefully read the plan documents to understand what is and isn’t covered, as well as any caps on benefits.

Claim process

Knowing how to file a claim and what to expect is vital. Most providers will handle billing directly with your insurance company for in-network services. However, if you go out-of-network or have a situation where you pay upfront, you’ll need to submit a claim yourself. Understand the typical turnaround time for claim processing and what documentation is required. This information is usually available on the insurance company’s website or in your policy documents.

Bundling and discounts (general)

Many insurance companies offer discounts if you bundle multiple types of insurance, such as home and auto. While health insurance is often separate, it’s worth asking about any potential savings. Additionally, some plans may offer discounts on services like gym memberships or alternative therapies. Look for these added benefits when comparing your options.

Step-by-step (simple workflow)

1. Assess your health needs:

• What to do: List your current health conditions, medications, and anticipated medical services for the year.
• What “good” looks like: A clear understanding of the types and frequency of healthcare you expect to need.
• Common mistake: Underestimating future health needs.
• How to avoid it: Be realistic and consider potential health changes or family planning.

2. Determine your budget:

• What to do: Calculate how much you can comfortably afford for monthly premiums and potential out-of-pocket costs (deductibles, copays, coinsurance).
• What “good” looks like: A defined spending range for health insurance costs.
• Common mistake: Focusing only on the monthly premium.
• How to avoid it: Factor in potential deductibles and out-of-pocket maximums.

3. Explore your options:

• What to do: Research the different avenues for obtaining health insurance.
• What “good” looks like: Awareness of employer-sponsored plans, the Health Insurance Marketplace, Medicare, Medicaid, and private plans.
• Common mistake: Not exploring all available avenues.
• How to avoid it: Do a thorough search and understand eligibility for each.

4. Check employer coverage:

• What to do: If you are employed, inquire about health insurance benefits offered by your employer.
• What “good” looks like: Understanding the employer’s plan details, costs, and coverage.
• Common mistake: Assuming employer plans are always the best or most affordable.
• How to avoid it: Compare employer plans side-by-side with other options.

5. Visit the Health Insurance Marketplace:

• What to do: Go to Healthcare.gov (or your state’s specific marketplace website) to compare plans.
• What “good” looks like: Browsing available plans, understanding their benefits, and checking for premium tax credits.
• Common mistake: Not applying for financial assistance.
• How to avoid it: Complete the application for subsidies carefully.

6. Review Medicare/Medicaid eligibility:

• What to do: If you are 65 or older, have a disability, or have a low income, check if you qualify for Medicare or Medicaid.
• What “good” looks like: Confirmation of eligibility and understanding the benefits of these government programs.
• Common mistake: Not applying because you think you won’t qualify.
• How to avoid it: Check the official eligibility criteria for your situation.

7. Consider private plans:

• What to do: If Marketplace or government plans aren’t suitable, look into plans directly from insurance companies.
• What “good” looks like: Understanding that these plans may not be eligible for subsidies and can vary widely in cost and coverage.
• Common mistake: Buying a private plan without checking if a Marketplace plan offers better value.
• How to avoid it: Always compare private plans to Marketplace options.

8. Compare plan details (premiums, deductibles, networks):

• What to do: Create a spreadsheet or list to compare key features of shortlisted plans.
• What “good” looks like: A clear side-by-side view of costs, coverage, and provider networks.
• Common mistake: Focusing only on the monthly premium.
• How to avoid it: Analyze the total potential cost, including deductibles and out-of-pocket maximums.

9. Check provider networks:

• What to do: Verify if your preferred doctors, hospitals, and specialists are within the plan’s network.
• What “good” looks like: Assurance that your current healthcare providers are covered.
• Common mistake: Assuming your doctor is in-network without verifying.
• How to avoid it: Use the plan’s provider search tool or call your doctor’s office.

10. Read the fine print (exclusions, limits):

• What to do: Carefully review the plan’s Summary of Benefits and Coverage (SBC) and policy documents.
• What “good” looks like: Understanding what services are excluded and any limitations on coverage.
• Common mistake: Skipping over the details of what’s not covered.
• How to avoid it: Pay close attention to the “Exclusions” and “Limitations” sections.

11. Enroll in your chosen plan:

• What to do: Follow the enrollment instructions for the plan you selected during the open enrollment period or a special enrollment period.
• What “good” looks like: Successful completion of the enrollment process and receiving confirmation.
• Common mistake: Missing enrollment deadlines.
• How to avoid it: Mark enrollment periods on your calendar.

12. Understand your policy:

• What to do: Once enrolled, familiarize yourself with your Member ID card, copays, coinsurance, and how to access care.
• What “good” looks like: Confidence in navigating your insurance benefits.
• Common mistake: Not understanding how to use your insurance before you need it.
• How to avoid it: Review your policy documents and contact customer service with questions.

Common mistakes (and what happens if you ignore them)

| Mistake | What it causes