Individual Health Insurance Options

Families not covered by an employer group health plan, self-employed people under age 65 and new permanent residents can obtain coverage through several types of individual health insurance.

Consumers pay 100% of negotiated charges for covered hospital, surgical, advanced imaging, etc. until the plan's Deductible has been satisfied and then only a Coinsurance percentage amount.  For some plans, consumers have a Copay for office visits and some prescription drugs before meeting the deductible. There may be an Emergency Room Fee on top of other charges.

Plans that comply with the Affordable Care Act (ACA) requirements for Minimum Essential Coverage (MEC) include no-cost preventive wellness care, pregnancy and maternity care, mental and behavioral health services, and provide comprehensive out-of-pocket cost protection that includes both medical and prescription drugs.  ACA-compliant plan designs are grouped into Bronze, Silver, Gold, and Platinum categories and require a valid Special Enrollment Period (SEP) - such as loss of group coverage or losing eligibility for parents' plan at age 26 - to sign up outside of the annual ACA Open Enrollment (Nov 1 - Jan 15).

Usually, open enrollment runs until Dec. 15th, but for this year 2023 coverage was extended to Jan. 15th. People who wait to sign up in Jan will have their coverage start on Feb. 1st.

Health plans that don't meet the ACA requirements can receive applications year-round and provide some risk protection for a lower insurance premium cost, but may exclude coverage for pre-existing conditions and deny enrollment based on health history.  Short Term Medical plans limit out of pocket costs for covered services during a certain period of months.  Indemnity plans provide a specific cash benefit for covered medical events - such as accident, critical illness, cancer diagnosis, hospitalization, etc. - when coverage is in force.  Business owners with a partner or employee may also want to consider a Small Group Health Plan.

Affordable Care Act (ACA) "On-Exchange" Plans offered by private companies through the Health Insurance Marketplace qualify for financial assistance based on current year household income (including any Social Security benefits) such as Advanced Premium Tax Credits (APTC) for households between 100% and 400% of the Federal Poverty Level (FPL) as well as lower deductibles and copays through Cost Sharing Reductions (CSR) for households between 100% and 250% of Federal Poverty Level (FPL).

On-exchange plans in Georgia use a Health Maintenance Organization (HMO) design that requires use of in-network providers and facilities outside of emergency situations.  Anthem contracts with Northside Hospital and requires a Primary Care Physician (PCP) referral to see a specialist.  Ambetter does not require referrals and contracts with Emory, Wellstar and many of their affiliated doctors. An agent/broker can assist with reviewing, selecting and enrolling in the HealthCare.gov plans.

Affordable Care Act (ACA) "Off-Exchange" Plans offered directly by private companies are not eligible for premium subsidies and always have built-in pediatric dental coverage.  In addition to HMO plans, Anthem BlueCross also offers off-exchange plans utilizing a broader PPO network that includes many more contracted providers as well as some out-of-network coverage.  Premiums can vary by county of residence, tobacco use and the ages of covered members, but getting help from an agent/broker makes no difference to your plan costs or choices.

High Deductible Health Plans (HDHP) that meet IRS guidelines - for 2022, a minimum deductible of $1400 for self only / $2800 for family coverage and an annual maximum out-of-pocket limit of $6,900 self / $13,800 family - establish eligibility for tax-deductible contributions to a Health Savings Account (HSA) - up to $3,550 inidividual / $7,100 family per year - plus an additional $1000 catch-up contribution for those over 55.  HSA compatible plans are offered both on-exchange and off-exchange.

Short Term Medical (STM) plans provide a limit on out of pocket expenses that may be incurred while the contract is in force.  They are not HSA compatible.  Premiums are most affordable for STM plans lasting 6 months or less, but a new application will be required for coverage at the end of each term and the deductible resets each time.  Several insurance companies offer three consecutive 12-month terms without the need to reapply regardless of a change in health conditions.  STM plans can be a good option for a period of transition between job-based coverage or as a bridge for a spouse too young for Medicare when a breadwinner retires.  UnitedHealthcare's UHOne line of STM plans uses the broad "ChoicePlus" network and offers a variety of deductible and coinsurance options.

Health Indemnity plans can help fill the gaps (i.e. deductible) in either ACA or STM plans.  Critical Illness plans may offer a lump sum benefit upon diagnosis of cancer, heart attack, stroke or certain other conditions.  A Cancer plan would only pay for that particular condition.  Accident health plans help with the hospital and medical costs following an accidental injury in addition to the life insurance or loss of limb benefits of an accidental death policy. Hospital Indemnity plans pay either a daily benefit or a per admission benefit for inpatient stays.  Umbrella health indemnity plans pay a benefit for doctor's office visits in addition to hospitalization, but they do not provide a limit on member out of pocket costs.