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Health Insurance Information
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How is individual insurance different from group insurance?
Individual health insurance is coverage an individual purchases for himself or his family.
Individual policies are often purchased with the advice of a professional insurance producer ("Agent") due to the complexity of coverage offerings and the premium cost. With all the new laws, rules and regulations that come as long with the ACA, a professional insurance producer’s expertise may be even more critical since insurance policies have changed significantly.
Whether or not a person has a pre-existing medical history is no longer a consideration when purchasing individual coverage. However, due to the fact everyone is GUARANTEED approval, a person must enroll during an “Open Enrollment Period” to gain coverage for the year. There are limited opportunities to purchase coverage at other times during the year as a result of a “Qualifying Event”.
Individual insurance policies may be purchased through an exchange or “marketplace” (CoveredCA) or they may be purchased outside of the exchange (“Direct”). It is important to note that if you are eligible for, and plan to take advantage of receiving a SUBSIDY from the State, then you MUST enroll THROUGH CoveredCA to obtain said subsidies. If you are not eligible for a subsidy, you DO NOT need to enroll through CoveredCA.
Irrespective of whether a policy is purchased inside or outside the exchange, polices must cover the same set of Essential Health Benefits.
The richness of the benefits under the plan is defined by a metal tier. These tiers are based on the percentage the plan pays of the average overall cost of providing essential health benefits to members:
Platinum plans are the most generous and more expensive. These are designed to pay as much as 90% of medical expenses
Gold plans are designed to pay 80% of medical expenses
Silver plans are expected to pay 70% of medical expenses
Bronze plans are expected to pay 60% of medical expenses.
It’s important to note that the metal tiers reflect what the plans will pay on average. These percentages are not the same as coinsurance, which calls for an individual to pay a specific percentage of the cost of a specific service.
Another category of individual plan is the catastrophic plan. A catastrophic plan must meet the requirements of the metal plans, but benefits are very limited. Catastrophic plans are an option for individuals under the age of 30 or others who have received a “hardship exemption” from the exchange due to other health coverage being deemed unaffordable.