Getting Covered
Summary
There are three main sources of health coverage. The first is your job. The second is a plan that you buy. The third is a government program for older, disabled or low-income people.
Through your job. Employers generally have to offer insurance to full-time workers. You also may be covered through your spouse’s or parent’s employer. If you are a college student, you may be covered through your school. Most often, you share the cost of your coverage with your employer. A premium is deducted from your paycheck. You may also have costs like deductibles, copays and coinsurance when you use your plan. (See Cost Sharing.)
Buy your own. You can buy coverage straight from an insurer. You can also buy it through exchanges (or marketplaces) set up through the Affordable Care Act (ACA). The marketplaces are open from November 1 to January 31 each year. You may be eligible to sign up at other times—for instance, if you lose your job. You generally pay a monthly premium for coverage. If you buy a plan through the marketplace, you might qualify for help paying your premium. You may also have costs like deductibles, copays and coinsurance.
To buy a marketplace plan, visit www.healthcare.gov, or your state’s marketplace site. You’ll see the costs and benefits for all of the plans in your area. You can also find out whether you qualify for premium help. Call 800-318-2596 for help understanding the different plan choices. Or, visit localhelp.healthcare.gov to find in-person help near you.
Public programs. Medicare gives low-cost health coverage to older adults and disabled people. Medicaid covers people who cannot pay for a plan. Does your family earn too much to get Medicaid? Your children may still qualify for low-cost coverage through the Children’s Health Insurance Program (CHIP). Medicare is national, but eligibility rules and coverage for Medicaid and CHIP differ for each state. For questions about Medicare, visit www.medicare.gov. Visit www.healthcare.gov to see if you qualify for Medicaid or CHIP, and to join.
Private and Public Sources of Health Coverage
Health insurance can help protect you and your family from unaffordable healthcare costs. There are three main sources of coverage: your employer, individual plans and government programs (public insurance).
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 percent 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 percent 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.
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.
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?