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 after pay 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 also 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) to sign up outside of the annual ACA Open Enrollment (Nov 1st - Jan 15th). Examples of SEP events include (but are not limited to) loss of group coverage or losing eligibility for a parent’s plan by turning age 26.
If you sign up between Nov. 1st and Dec. 15th, your effective date (when the coverage begins) will be Jan. 1st. If you sign up between Dec. 16th and Jan. 15th, the effective date is Feb. 1st.
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). Beneficiaries with income between 100% to 150% of FPL are entitled to a continuous SEP throughout the whole year. Since 2022, if your income level is at or above 100% of the FPL, your premiums will not exceed 8% of your current year’s income, and the tax credit that will be used in these cases will ensure that you do not incur a higher cost than that.
On-exchange plans in Georgia use a Health Maintenance Organization (HMO) system 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 GeorgiaAccess.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. 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.
Individuals can apply for health plans that don't meet the ACA requirements year-round and these plans do 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 accidents, critical illnesses, cancer diagnosis, hospitalizations, etc.) when coverage is in force. Business owners with a partner or employee may also want to consider a Small Group Health Plan.
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. Plans can last up to 4 months and then beneficiaries are required to apply for a new plan with a different company. 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.
High Deductible Health Plans (HDHP) that meet IRS guidelines - for 2025, a minimum deductible of $1,600 for self only / $3,300 for family coverage and an annual maximum out-of-pocket limit of $8,300 self / $16,600 family - establish eligibility for tax-deductible contributions to a Health Savings Account (HSA) - up to $4,300 individual / $8,550 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.