How To Get Health Insurance – Forbes Advisor - Forbes

It's challenging to find the best health insurance plan for you or your family's needs that stays within your budget. While health insurance is no longer mandatory as of 2019, it's still required in many states. Whether you're uninsured—as are approximately 33 million Americans—or need to find better, more affordable coverage, this guide to buying health insurance can help.

What Is Health Insurance?

Health insurance is a contract between an insurance provider and an insured party that requires the provider to cover medical expenses related to illnesses, injuries or other conditions. These expenses may include doctor visits and consultations, hospitalization, emergency services, surgery, laboratory tests, prescription medication, maternity and newborn care, mental health, ambulance rides and rehabilitation services. Health insurance may also cover some dental expenses, though separate dental insurance is common.

Health insurance generally doesn't cover cosmetic procedures like plastic surgery, laser hair removal or body contouring, nor does it cover fertility treatments, off-label prescription use or new and experimental technologies. Exactly what health insurance does cover varies by plan, provider and state.

What Types of Coverage Exist?

Health insurance coverage comes in three major types: employer-sponsored health insurance (ESI), individual or private plans and Medicare/Medicaid. In the last decade, the number of private employers offering employer-sponsored insurance decreased significantly, from 61.6% in 2008 to 47.3% in 2018, according to the Agency for Healthcare and Research Policy. In 2010, President Obama signed the Affordable Care Act (ACA) into law, which made private health insurance significantly more accessible to uninsured Americans and expanded eligibility to Medicaid.

Insurance Through Your Employer

Employer-sponsored health insurance is a health plan chosen and primarily paid for by your employer. These plans are also offered to or can include your dependents (usually spouses and children). Your employer chooses which plan options are available to you and splits the cost of premiums. You can also pay your premiums on a pre-tax basis, which lowers your taxable income.

Individual Health Insurance

Individual health insurance, also known as a personal health plan, is a policy you buy either for yourself or your family. These plans allow you to find coverage that best suits your needs and may include your preferred doctors and hospitals. Since your coverage isn't provided by your employer, you may change jobs at any time without risking the loss of your insurance coverage. You can renew or change your health insurance plans or options annually.

Medicare and Medicaid

Medicare is a federal program that provides health insurance for people over 65 and for people under 65 with a disability, end-stage renal disease or amyotrophic lateral sclerosis (ALS). Medicaid is a state and federally run program that provides health insurance to eligible low income Americans, pregnant women, children, people with disabilities and elderly adults.

You may be dually eligible for Medicare and Medicaid. If you think you're eligible for either of these programs, visit medicare.gov and medicaid.gov to learn more and apply.

Ways to Get Health Insurance

If you need to purchase individual health insurance, learning about options and resources can help you choose what's best for you and your family.

The Government Health Insurance Marketplace

The Health Insurance Marketplace was established by the Affordable Care Act in 2010 to provide insurance plans to individuals, families and small businesses. Through this online resource, you can learn more about health insurance, compare plans, enroll in a plan and more. Finding and purchasing a health insurance plan through the marketplace may qualify you for subsidies—health insurance at a low or no cost—depending on your income. You can also purchase a policy through the marketplace even if you're offered insurance by your employer; however, you may not qualify for subsidies if you have access to employer-sponsored coverage.

To buy a policy through the marketplace, you must apply during open enrollment or special enrollment. Open enrollment for 2022 coverage begins Nov. 1, 2021 for the federal marketplace and runs until Jan. 15, 2022. To have your coverage start by Jan. 1, 2022, enroll in your plan by Dec. 15, 2021.

Some state exchanges may have slightly different open enrollment periods. If you miss open enrollment, you may qualify for a special enrollment period due to a major life change like moving, getting married, having a child or losing your existing health coverage.

To begin your search for insurance through the marketplace, head to Healthcare.gov during open enrollment and enter your ZIP code. It will direct you to either your state's exchange or to the federal marketplace where you can begin shopping.

A Health Insurance Broker or Agent

A health insurance broker or agent is a trained professional who can help you navigate the wide range of insurance options and enroll in the best health insurance plan for you. An agent may work for a single health insurance company while a broker will represent several companies at once. You don't pay any fees when working with agents or brokers, as they're paid on commission for selling you a plan.

To find a broker or agent, you can use the federal government's Find Local Help tool to set up in-person, phone or email appointments. You can also enter your phone number or email address to be contacted by an agent or broker to talk about plan choices. Agents and brokers must be licensed in their states to sell health insurance and are often required to act in the best interest of the customer.

Direct From Insurer

Some people may find plans that better fit their specific needs or budget by shopping directly with health insurance companies. These outside-of-marketplace plans exist only in a few limited cases and must still meet all minimum essential coverage requirements of the ACA. Purchasing a plan outside of the marketplace removes the opportunity for premium tax credits or other subsidies that are available through the marketplace.

Online Insurance Brokerage

In 2019, the Trump administration permitted the sale of marketplace plans through private websites, also known as "direct enrollment" sites or "private exchanges." These sites are run by insurance companies like Blue Cross Blue Shield, Cigna and Ambetter, as well as by brokers, who offer plans from competing insurers.

These private enrollment websites come with a few caveats. First, a private exchange run by a private insurer typically only shows their own marketplace plans—not any of their competitors' policies. Second, these private web brokers may display plans that pay them higher commissions first. Finally, the private sites are allowed to sell plans that don't meet the ACA's minimum essential coverage requirements, and "secret shoppers" who have tested these sites have expressed concern about inaccurate representation of health insurance plans. You can always check Healthcare.gov if you have any concerns about the information available on private exchange websites.

Membership Organizations

People who don't have employer-provided health insurance, are self-employed, are unemployed or own small start-ups may be eligible for a group health plan. These health plans require membership to a professional, trade or membership organization. Organizations providing such group health plans include AARP, National Association of Female Executives, the Writer's Guild of America and the Freelancers Union.

Be wary of plans provided through some membership organizations, as many offer a "health services discount" plan that may save you money on prescriptions but isn't a true health insurance plan.

Customers shopping outside the marketplace should also be cautious of healthcare-sharing ministries, where individuals of a shared faith contribute money to a health care cost pool distributed by a ministry to pay for certain health-related expenses. This is not health insurance and doesn't cover pre-existing conditions or guarantee reimbursements.

When Should You Sign Up for Health Insurance?

The best time to sign up for health insurance is before you need it. Open enrollment for private health insurance through the federal marketplace (and many state marketplaces) begins on Nov. 1 and runs until Jan. 15.

Special Enrollment Periods

You may qualify to enroll in health insurance during what's called a special enrollment period if you have a qualifying life event. Qualifying events for special enrollment include:

• Losing your health coverage through a life event
• Getting married or divorced
• Having or adopting a child
• Moving to a new state
• Aging out of a parent's health insurance plan

Special enrollment periods typically last 60 days after your qualifying event, so begin applying for special enrollment as soon as possible to avoid missing the window.

Short-Term Medical Plans

If you don't qualify for a special enrollment period or need to purchase health insurance outside of the open enrollment period, a short-term medical plan may be available to you. These plans often don't meet the ACA's minimum essential coverage requirements or cover pre-existing conditions. These plans are regulated to last no more than 364 days and are not available in every state.

Common Health Insurance Scams

Common health insurance scams include robocalls and phishing emails that push "comprehensive" health plans that meet the requirements of "Obamacare" or "Trumpcare." Some emails feature the logos of well-known insurers or organizations like AARP.

During open enrollment, live callers impersonate representatives of the insurance marketplace, offering special rates or encouraging you to join an association or union to get covered. Government representatives will never call to try and sell you insurance, nor will they push you with high-pressure sales pitches.

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