Individual Health Insurance Plans – Basics

What is an Individual Health Insurance Plan?

An individual health insurance plan is a plan purchased individually through a private insurance company. It may be a plan for an individual, individual and spouse, individual and children, or for an entire family. The insurance pays for medical expenses in exchange for a premium.

The majority of Individual Health Insurance plans are Managed Health Plans. Managed Health Plans refer to plans that use techniques to manage the cost, access, and quality of healthcare.

Individual Health Eligibility

Anyone under the age of 65 and not eligible for Medicare is eligible for Individual health coverage.

Who needs Individual Health Insurance Plans?

Individuals who are:

  • Self-employed and are not eligible for the group coverage
  • Employees of companies not offering medical benefits
  • Retired but not yet entitled to Medicare
  • Recent college graduates
  • Dropped by existing insurer
  • Unemployed

Individual Health Insurance Costs

  • Premium – This monthly premium should be paid to insurance companies to keep your policy in effect.
  • Deductible – The annual amount you are required to pay for medical services upfront out of pocket before the insurance company will pay for your medical claims.
  • Copay – The specific dollar amount you are required to pay for the particular type of service; for example, a copay for a visit to the doctor.
  • Coinsurance – The percentage from the based amount (such as 20%) you are required to pay for a specific type of service; for example, you may be responsible for 20% of the full outpatient surgery bill.
  • Out-of-Pocket Maximum (MOOP) – The most you may need to pay out of pocket for your healthcare in one calendar year. Once you reach this limit, the insurance company pays 100% of covered.

Individual Health Insurance: Managed Health Plans

Benefits are the most extensive for Managed Health plans. The two most popular types of Managed Health Plans are HMO and PPO.

Managed Health Plans Benefits

Managed Health plans benefits include:

  • Hospitalization
  • Physician Services
  • Many outpatient services
  • Emergency care
  • Diagnostic services and lab tests
  • Inpatient and short-term rehabilitation services
  • Health evaluations and examinations

Health Maintenance Organization (HMO)

HMO is a form of managed care providing a wide range of comprehensive healthcare services.  Within this plan, there is an emphasis on prevention and wellness services.

There is a network of doctors, hospitals and other care providers in HMO. Providers deliver medical care to HMO members in exchange for negotiated compensation. Service is ONLY within the network.

The role of primary care providers (PCPs) in HMO is significant. They not only provide primary care services but also serve as gatekeepers to other doctors. Usually, to see a specialist, you must obtain a reference from your PCP.

In addition to medical coverage, HMO provides coverage for special services such as vision care, dental care, and prescription drugs.

Preferred Provider Organization (PPO)

PPO is a form of managed care covering a wide range of comprehensive healthcare services.

PPO has a network of doctors, hospitals and other care providers, known as Preferred Network. Its providers deliver services to PPO members based on discounted fees. Your claims will be paid at the highest level if you are visiting doctors within the network. You also may visit doctors outside the net, but the network care is less expensive than care outside of the system.

You may visit a specialist without the need to visit the primary care provider (PCP); references are not required.

Most PPOs have a deductible and coinsurance.

Individual Health Insurance Plans: In Depth

See Individual Comprehensive Major Medical Plans for in-depth review of the Affordable Care Act (ACA) compliant plans.

See Short Term Medical Plans for in-depth review of Short Term Medical Insurance.

See Supplemental Insurance Plans for an in-depth review of Supplemental insurance coverage.

Let Liberty Medicare help you choose Individual Health Plan

Liberty Medicare is here to help you during every stage of selecting and enrolling in the best and most suitable Individual Health Plan for you. All of our services are offered to you at no cost.

Liberty Medicare represents many well-known Individual Health providers and Supplemental providers in Delaware, Maryland, New Jersey, and Pennsylvania.  Learn more about all the benefits of working with Liberty Medicare.

If you are considering buying an Individual Health insurance, let us guide you. To see real quotes from insurance providers, fill out our Individual Health Quote form or give us a call at 877-657-7477.