English   |   Español
LEARN
Benefit Basics
divider Health Coverage Plan Costs In and Out of Network Know Before You Go Types of Care Bills and Documentation Your Rights

Getting Covered

 

Private and Public Sources of Health Coverage

print

 

 

Health insurance can help protect you and your family from unaffordable healthcare costs. And, under the Affordable Care Act, everyone must have health insurance or pay a penalty. Of course, this rule has some exceptions, which you can learn more about here. There are three main sources of coverage: your employer, individual plans and government programs (public insurance).

 


Through Your Job or a Family Member’s Job

Most people in the U.S. get health coverage through their jobs. In general, employers are required to offer insurance to full-time staff. You may also be covered through your spouse or parent if their employer provides family coverage, or, if you are a college student, through your school. Your employer may run their own “self-administered” plan, or buy a plan through an insurance carrier that they then offer to you. Some employers just offer one plan, while others give you a range to choose from, all with different benefits and costs. You may have the option of covering yourself or your whole family, or choosing between different plan types like HMOs, PPOs or high-deductible plans. Generally, you pay a monthly premium that comes out of your paycheck automatically, and your employer pays a portion as well. You will also usually have some out-of-pocket costs when you use your coverage, like deductibles, co-payments and co-insurance.  If you work for a union that has agreements with more than one employer, you may be able to keep your coverage when you change jobs. If you just work for one employer, your coverage will end when you leave your job.  You also may lose your insurance if you become a part-time employee. But, you may be eligible for COBRA continuation coverage, which allows you to stay in the plan for a time by paying the full cost of coverage yourself.


Buy Your Own

If you aren’t covered through your job or a family member’s job, you can buy coverage directly from an insurance company, or through special marketplaces set up through the Affordable Care Act.

Marketplace Plans

Your own state may have a marketplace website, or you can visit the national marketplace at www.healthcare.gov.  When you apply for coverage through the marketplace, you’ll answer a series of questions about your income, family size, and other factors to find plans near you, and determine if you are eligible for a tax subsidy to help pay your premium. Then, you will need to decide whether you want single or family coverage, and choose from a range of plans with different benefits and costs. Besides the monthly premium, you will usually have some out-of-pocket costs when you use your coverage, like deductibles, co-payments and co-insurance.  Anyone may enroll in a health plan through the marketplace from November 1 to January 31. Some people may be eligible to enroll during other times of the year. In some cases, you can also buy a plan at other times of the year, for instance, if you lose your coverage because you leave your job or your work hours are reduced.

The marketplace offers four levels of plans. Each level is priced differently and covers a different amount of the cost of your care. “Bronze” plans have the lowest monthly premiums, but you will pay higher co-pays and deductibles when you need care. “Platinum” plans have the highest monthly premiums, but have low co-pays and deductibles. If you have a chronic condition, or need care regularly, you may want to choose a platinum-level plan to control your out-of-pocket costs. Or, if you are young and generally healthy, the low premiums of a bronze plan may outweigh the higher costs you’ll pay when you do occasionally visit the doctor.  Some individuals, like young adults under 30 who are facing a financial or other hardship, may also be able to buy “catastrophic” plans. These plans have very low premiums, but the deductibles are extremely high. They are only meant to protect you in the case of a very serious accident or illness.

The chart below shows how much of the cost of your care you can expect to pay at each Marketplace plan level. This does not include your monthly premium. Keep in mind that this is an estimate of the total cost of your care over the year, not the amount for a specific service or treatment.

Market Plan Level Premium Cost Your plan pays You pay (co-pays,
co-insurance, and deductibles
Bronze Lowest 60% 40%
Silver   70% 30%
Gold   80% 20%
Platinum Highest 90% 10%
Catastrophic
(not available to everyone)
  Less than 60% More than 60%

Source: https://www.healthcare.gov/choose-a-plan/plans-categories/


Sorting through all this information can be difficult, so many community-based organizations have trained “health insurance navigators” to guide people through their plan choices and help them enroll. You can find a navigator to help you in person or over the phone by visiting https://localhelp.healthcare.gov/.


Public Programs

There are government programs that offer affordable health coverage to the elderly, disabled and people who cannot pay for a plan.

Medicare covers the elderly and disabled. You become eligible for Medicare when you are 65 or older, or are permanently disabled and have been receiving a Social Security disability pension for two years.  Medicare has several different “parts” that cover different services. You can visit any doctor or provider that accepts Medicare. If your income is low, you may be able to get help paying some Medicare costs. You can apply for Medicare online at www.socialsecurity.gov, or at your local Social Security office.

  • Medicare Part A covers hospital care, and there is no monthly premium.  However, there is a yearly deductible, and co-insurance if you are in the hospital for more than 60 days.
  • Medicare Part B covers doctors’ visits and medical services, and there is a monthly premium based on your income.  You also pay 20% of the cost for doctor’s visits and most medical services.
  • Medicare Part D covers prescription benefits. Medicare does not offer these plans directly. Instead, you purchase a Part D plan through a private insurer. The monthly premium for your plan will depend on your income, and the amount of coverage that you choose.  You may also have co-pays for your medications, and have to choose medicines from a preferred list, or formulary.
  • To help cover costs that Medicare does not pay, you can enroll in a Medicare Advantage Plan (Medicare Part C).
    These plans usually cover prescription drugs, your 20% co-insurance for medical services, and extra benefits that regular Medicare does not offer, like vision, hearing and dental.  You purchase these plans through a private insurer, and they operate like private insurance. You use a specific provider network, usually an HMO or PPO.  You generally pay the monthly Part B premium, and may also have an additional Medicare Advantage premium, depending on the plan you choose.

Medicaid covers people who cannot afford health insurance. States administer their own Medicaid programs, and eligibility, coverage and costs are different in each state. In some states, all adults below a certain income level are eligible. Your eligibility depends on factors like your age, income, your citizenship or immigration status, the number of people in your family, whether you are pregnant, and whether you have a disability. If you apply for coverage through Healthcare.gov, or your state’s health insurance marketplace, the site will automatically determine if you are eligible for Medicaid in your state. Most state programs have co-payments, co-insurance and deductibles, but they are very low. You can apply for Medicaid any time, and do not have to wait for an open enrollment period.

The Children’s Health Insurance Program (CHIP) covers children whose family income is too high to be eligible for Medicaid. Some state programs also cover parents and pregnant women. States administer their own CHIP programs, so eligibility, coverage and costs may be different from state to state. Most state programs have co-payments, co-insurance and deductibles,
but they are very low. You can apply for CHIP any time, even outside open
enrollment periods.


If you are covered by more than one plan

In some cases, you may be covered by more than one health plan. You might qualify for both Medicare and Medicaid, or you and your spouse may both have family coverage through your employers.  In that case, the two plans will “coordinate” the payments for your care. Make sure to show both your health insurance ID cards when you visit the doctor or get care.

Please keep in mind that the medical and dental reimbursement cost estimates that you receive from the FAIR Health consumer website are relevant for private health plans, not public insurance plans.


Your Action Plan

  • When choosing a health plan through your employer, the marketplace or a private insurer, ask:
  • What type of plans are offered? How much does each cost?
  • Is there a deductible? How much are co-pays and co-insurance?
  • Are your current doctors in the network? Is your preferred hospital? If you are buying a plan through the marketplace, make sure your doctors participate in that insurer’s marketplace plan, which is sometimes smaller than their regular network.
  • How many network providers are close to where you live and work?
  • Does the plan cover out-of-network care, and if so, what does it pay?
     
  • If you don’t have coverage through your job, visit www.healthcare.gov first. After answering some questions, you will learn about individual plans in your area, whether you qualify
    for a tax subsidy to help pay for your plan, and if you are eligible
    for public coverage, like Medicaid or CHIP.
     
  • If you need help sorting through your marketplace options and finding the best plan for you, you can call a navigator at (800) 318-2596 or visit https://localhelp.healthcare.gov/ to find in-person assistance near you.
  • If you have questions about Medicare coverage, or to find a Medicare Prescription Drug Plan or Medicare Advantage Plan, visit www.medicare.gov