How Individual and Family Plans Work
Individual and Family Plans work the same way as your group health plan. As with group health plans, Individual and Family Plans act as a safety net for your wallet, protecting you from the high costs of medical care and providing a maximum amount you spend.
Purchasing a Plan
When You purchase an Individual and Family Plan, your medical history and any current medical conditions can’t be considered in pricing the plan. However, your age, where you live, tobacco usage, and family size are factors in the plan’s price.
If you have a gap in coverage, you may want to purchase a Short-Term Medical Plan (STM). An STM provides temporary coverage for people that need quick and affordable health insurance. Read Short-Term Medical Plans to learn more.
After You Purchase a Plan
After purchasing an Individual and Family Plan:
You pay a monthly fixed premium to the insurance carrier, which gives you access to a defined set of doctors, hospitals, and clinics that provide services covered by your plan.
The insurance carrier issues you a policy that describes what is and isn’t covered by the plan. The policy also provides the copay or coinsurance amount that you're responsible for when using your benefits.
How Coverage Levels Work
Individual and Family Plans offer different levels of coverage: bronze, silver, gold, and platinum. You may choose the level of coverage that best meets your needs and budget. These levels help when you shop and compare plans.
A plan’s metal level indicates the amount of coverage it provides, on average, and how much the plan pays for medical expenses.
Platinum and gold plans generally have higher premiums than bronze and silver plans because the insurance carrier covers more of the medical costs. Silver and bronze plans generally have lower premiums than platinum and gold plans because you cover more of the medical costs..
Provided Health Care Services
Qualified health plans sold in the Public Marketplace and every health plan offered in the Private Marketplace must offer the following 10 essential health benefits regardless of the plan’s metal level. As long as you’re in network, the benefits apply.
Ambulatory patient services (outpatient care you get without being admitted to a hospital)
Emergency services
Hospitalization, such as surgery and overnight stays
Pregnancy, maternity, and newborn care before and after birth
Mental health and substance use disorder services, including behavioral health treatment (counseling, psychotherapy, etc.)
Prescription drugs
Rehabilitative and habilitative services and devices to assist people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills
Laboratory services
Preventive, wellness services, and chronic disease management
Pediatric services, including dental and vision care for children
There are no annual or lifetime limits on these plans.
Covered Services Reminders
In general, you must pay a portion of the cost for any service you receive, except for preventive services, which are covered at 100% when provided by a network provider.
Although health plans have excellent coverage, they don’t cover everything. Every plan has a list of exclusions or non-covered services, such as elective services. Contact your carrier for more information.
Deductibles
The deductible is the amount you pay for covered health care services before the insurance carrier begins to pay. After meeting the plan’s deductible, you typically pay a copay or coinsurance for any covered service, and the insurance carrier pays the rest.
Family plans often have both individual and family deductibles. The individual deductible applies to each person on the plan, while the family deductible applies to every family member on that plan. Every individual deductible contributes to the family deductible.
Out-of-Pocket Maximums
Out-of-Pocket Maximum
The maximum out-of-pocket expense is the most you're required to pay for covered services in a plan year. After you spend this amount on deductibles, copays, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits for the rest of the plan year.
Family Out-of-Pocket Maximums
Any expenses paid by individuals go toward the family’s out-of-pocket maximum. When the family out-of-pocket maximum is met, the plan pays 100% of each individual’s out-of-pocket costs for covered services for the rest of the plan year.