Individual Health Insurance 101 Guide
Posted by Anna Koehler on Dec 3, 2014 in Health Insurance News
Introduction
Health insurance is a crucial but often complicated part of the healthcare system, and it is not always as
easy to understand as straightforward medical bills or even other forms of insurance. However, health
insurance is much more than just an added hassle to the doctor-patient relationship. It is a key safeguard
that can enhance your quality of life for decades to come.
When you first receive information about your individual insurance package, you might feel a bit
overwhelmed. The complex terminology and mechanics of insurance policies can be daunting, and you
might be uneasy about spending a portion of your paycheck in return for something that may not be of
use to you for some time. There is also the anxiety that comes with wondering how to take full advantage
of your policy, knowing that these are big decisions which can have a significant, long-term impact.
This guide is intended to provide you with the basics about health insurance benefits so you are able to
more easily understand what your options are when choosing a health insurance plan.
Health Insurance Basics
How Does Health Insurance Work?
Health insurance is an arrangement with an insurance company that can help protect you from the high
costs of health care. At its most basic, you pay premiums and the insurance company agrees to pay part
of your medical expenses for illnesses or injuries, prescription drugs and preventive care.
Health insurance works by spreading the cost of care among large groups of people—so insurance paid
by one person helps pay for the care of others. In a large enough group, most people are healthy and use
few health services in a given year. A minority of individuals account for the majority of health care
spending for the group. Because it is likely that every person will, at some point, get sick, be injured or
even become disabled, sharing this risk is a critical part of insurance.
In addition to spreading financial risk, health insurance has another important function: improving access
to health care services. In general, doctors and hospitals are more likely to care for people when they
know they will be paid. Numerous studies have shown that people without health insurance receive far
fewer health services (or delay needed health care) compared to insured people. Health insurance not
only protects individuals from catastrophic expenses, it also improves access to important routine,
preventive and primary care services.
There are several different types of health insurance that provide a range of coverage for medical
expenses. Expenses vary based on how much coverage someone signs up for and the number of family
members he or she decides to cover. Some types of insurance allow individuals to set aside pre-tax
income for use at a later date.
Depending on the type of health insurance coverage, either the individual pays costs out of pocket and is
then reimbursed, or the insurer makes payments directly to the provider.
After every visit to a health care provider, you will get a document called an explanation of benefits (EOB)
that shows what your insurance will pay and what your out-of-pocket expenses will be.
Group Health Insurance
Health insurance can be acquired in several ways. Among the most common is to obtain insurance is
through packages offered by employers. This method is called group health insurance. Group health
insurance often leads to lower rates for the coverage because the financial risk is spread out over many
people, most of whom are in good health.
Individual Health Insurance
Individual health insurance is health coverage that is purchased by an individual or a family that is not tied
to a job or a group of policyholders.
Health Insurance Terminology
The world of health insurance has many terms that can be confusing. Understanding your costs and
benefits—and estimating the price of a visit to the doctor—becomes much easier once you are able to
make sense of the terminology.
Participants
There are a number of participants involved in health insurance. The “provider” is a clinic, hospital, doctor,
laboratory, health care practitioner or pharmacy. The “insurer” or “carrier” is the insurance company
providing coverage, the “policyholder” is the individual or entity that has entered into a contractual
relationship with the insurance company and the “insured” is the person with the health insurance
coverage. For individual health insurance, you may be both the policyholder and the insured.
Premium
A premium is the amount of money charged by an insurance company for coverage. The cost of
premiums may be determined by several factors, including age, geographic area, number of dependents
and tobacco consumption. Policyholders pay these rates annually or in smaller payments over the course
of the year, and the amount may change over time. When insurance premiums are not paid, the policy is
typically considered void and companies will not honor claims against it. Self-employed persons may
deduct the cost of their individual health insurance premiums from their taxes.
Premium Example
Mary purchases a yearlong individual heath insurance policy. The total premium cost is $2,580, to be paid in monthly
installments. Therefore, Mary’s monthly premium is $215.
Copayment
A copayment, or copay, is a fixed amount you pay for a covered health care service, usually when you
get the service. The amount can vary by the type of covered health care service.
Copayment Example
Sally takes her son to the pediatrician for a bad cough. She has a copay of $15 at the doctor’s office.
Cost of Visit: $200
Sally pays: $15
Health plan pays: $185
Deductible
A deductible is the amount you owe for health care services each year before the insurance company
begins to pay. For example, if your annual deductible is $1,000, your plan won’t pay anything until you’ve
met your $1,000 deductible for covered health care services that are subject to the deductible. The
deductible may not apply to all services, such as preventive care services.
Deductibles are useful for keeping the cost of insurance low. The amount varies by plan, with lower
deductibles generally associated with higher premiums. They are fairly standard on most types of health
Deductible Example
John has a health plan with a $1,000 annual deductible. John falls off his roof and has to have three knee surgeries,
the first of which is $800. Because John hasn’t paid anything toward his deductible yet this year, and because the
$800 surgery doesn’t meet the deductible, John is responsible for 100 percent of his first surgery.
Coinsurance
Coinsurance is your share of the costs of a covered health care service calculated as a percent (for
example, 20 percent) of the allowed amount for the service. You pay coinsurance plus any deductibles
you still owe for a covered health service.
Coinsurance Example
John’s second surgery occurs in the same plan year as his first surgery and costs a total of $3,200. Because he has
only paid $800 toward his $1,000 annual deductible, John will be responsible for the first $200 of the second surgery.
After that, he has met his deductible and his carrier will cover 80 percent of the remaining cost, for a total of $2,400.
John will still be responsible for 20 percent, or $600, of the remaining cost. The total John must pay for his second
surgery is $800.
Out-of-pocket Maximum (OOPM)
An out-of-pocket maximum is the most you should have to pay for your health care during a year,
excluding the monthly premium. It protects you from very high medical expenses. After you reach the
annual out-of-pocket maximum, your health insurance or plan begins to pay 100 percent of the allowed
amount for covered health care services or items for the rest of the year.
Some health plans do not count all of your out-of-pocket expenses when determining the out-of-pocket
maximum. For example, some plans do not count your annual deductible, copayments, coinsurance
payments, out-of-network payments or other expenses toward this limit.
Out-of-pocket Maximum Example
John’s third surgery occurs in the same plan year as his first two surgeries and costs a total of $8,000. John has
already met his deductible, so he only needs to pay the coinsurance on this surgery, up to the plan’s out-of-pocket
maximum (OOPM) of $3,000. Without an OOPM, John’s coinsurance total for this surgery would have been $1,600
(20 percent of the $8,000 total), but because John’s plan allows his deductible to be counted toward his OOPM, John
has already spent $1,600 towards his OOPM on previous health care costs this year. Because of this, he only needs
to spend $1,400 before he hits his $3,000 OOPM. Once he hits the OOPM, his plan covers the remaining costs.
Therefore, John’s coinsurance total for the third surgery is $1,400—the 20 percent coinsurance cost, up to the $3,000
maximum—and his plan’s total is the remaining $6,600 (on the chart, this is shown as $5,600 before the OOPM, plus
$1,000 after John hits his OOPM).
Preventive Care
Preventive care is medical checkups and tests, immunizations and counseling services used to prevent
chronic illnesses from occurring. Rather than waiting for a patient to become sick, preventive care aims to
keep people healthy, or at least catch illnesses at their earliest and most treatable stages. Preventive
care includes preventive and diagnostic services performed by providers, such as annual physicals or biannual
mammograms. Under the provisions of the Affordable Care Act (ACA), non-grandfathered health
insurance policies must cover various preventive services for men, women and children without sharing
the cost for these services through coinsurance, deductibles or copayments. Some health plans may
have additional no-cost preventive services beyond what the law requires.
Preventive Care Example
Mary schedules an appointment with her in-network health care provider for an annual physical and bi-annual
mammogram. Because Mary is eligible for these preventive services under the ACA’s preventive care coverage
guidelines, the total cost of the visit is covered by her health insurance.
Cost of Physical $200Cost of Mammogram $200
Mary Pays $0
Health Plan Pays $400
Other Terminology
Essential Health Benefits
Essential health benefits are a set of health care service categories that the ACA requires certain plans to
cover, beginning in 2014. The plans that must cover essential health benefits include plans offered in the
individual and small group markets and all Medicaid state plans. Essential health benefits must include
items and services within at least the following 10 categories: ambulatory patient services; emergency
services; hospitalization; maternity and newborn care; mental health and substance use disorder
services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services
and devices; laboratory services; preventive and wellness services and chronic disease management;
and pediatric services, including oral and vision care.
Annual Limit
The annual limit is a cap on the benefits your insurance company will pay in a given year while you are
enrolled in a particular health insurance plan. These caps are sometimes placed on particular services,
such as prescriptions or hospitalizations. Annual limits may be placed on the dollar amount of covered
services or on the number of visits that will be covered for a particular service. After an annual limit is
reached, you must pay all associated health care costs for the rest of the year. As part of healthcare
reform, annual dollar limits can no longer be applied to a plan’s essential health benefits.
Lifetime Limit
The lifetime limit is a cap on the total lifetime benefits you may get from your insurance company. An
insurance company may impose a total lifetime dollar limit on benefits (such as a $1 million lifetime cap)
or limits on specific benefits (such as a $200,000 lifetime cap on organ transplants, or one gastric bypass
per lifetime) or a combination of the two. After a lifetime limit is reached, the insurance plan will no longer
pay for covered services. Under the ACA, insurance companies cannot set a dollar limit on what they
spend on essential health benefits for your care during the entire time you are enrolled in that plan.
Qualified Medical Expense
Qualified medical expenses are defined by the IRS as the costs attached to the diagnosis, cure,
mitigation, treatment or prevention of disease, or for the purpose of affecting any structure or function of
the body. To be eligible as qualified medical expenses, these expenses must be to alleviate or prevent a
physical defect or illness. They can include payments to providers, including dentists and optometrists,
and payments for prescription and over-the-counter medication. They do not include cosmetic procedures
or expenses that are only beneficial to general health, such as vitamins. The IRS publishes a full listing of
qualified medical expenses every year.
Grandfathered Plans
A grandfathered plan is a health insurance plan that was in effect before the ACA became law and has
basically stayed the same since then. They can continue to enroll people and offer coverage while
maintaining their grandfathered status. Grandfathered plans are exempt from some of the ACA’s reforms.
To find out if your health plan is grandfathered, check your plan’s materials describing benefits.
Summary of Benefits and Coverage
Summaries of benefits and coverage (SBC) are easy-to-read outlines that let you make apples-to-apples
comparisons of costs and coverage between health plans. You can compare options based on price,
benefits and other features that may be important to you. You’ll get an SBC when you shop for coverage,
when you renew or change coverage or when you request an SBC from the health insurance company.
Health Care Reform
Congress passed the ACA, a significant health care reform law, in March 2010. The ACA is a far-reaching
law that affects all aspects of the health care system. Consumers, health care providers and insurance
companies are all affected. The parts of the law that most affect you are described below.
Individual Mandate
The ACA requires most individuals to obtain acceptable health insurance coverage for themselves and
their family members or pay a penalty. If you are covered under an individual health plan, or if you are
currently covered by a government program such as Medicare, you can continue to be covered under
those programs.
There is a graduated tax penalty, or fee, for individuals who do not obtain health insurance by the time
they file their taxes for 2014. While at first the penalty is fairly modest, it substantially increases over the
following two years. In addition to the penalty, people without health insurance will still be responsible for
100 percent of the cost of their medical care. The fee schedule is as follows:
There are a very limited number of exceptions to the insurance mandate, mainly affecting non-citizens,
American Indians, incarcerated individuals, religious objectors and people suffering from poverty or
hardship. Exceptions are also available for people with short gaps in coverage of less than three months.
Health Insurance Marketplace
The ACA calls for the creation of health insurance Marketplace, also known as Affordable Health
Insurance Exchanges, for individuals and small businesses to purchase private health insurance. The
Marketplace allows for direct comparisons of private health insurance options on the basis of price,
quality and other factors, and coordinates eligibility for premium tax credits and other affordability
programs. The Marketplace became operational in 2014. Uninsured people who want to comply with the
individual mandate can use the Exchanges to fulfill their requirement.
Annual Limits and Pre-existing Conditions
As noted earlier, annual dollar limits cannot be placed on coverage for essential health benefits.
Additionally, the ACA compels insurers to cover individuals with pre-existing conditions. Insurance
companies cannot turn you down or charge you more because of your condition, nor can they refuse to
cover treatment for pre-existing conditions. The only exception is for grandfathered individual health
insurance plans. If you have one of these plans, you can switch to a Marketplace plan during open
enrollment and get coverage for your condition.
Types of Health Insurance Plans
Besides terminology, another factor that makes understanding insurance difficult is the number of
different health insurance plans available, each with its own set of rules. There are a number of reasons
why there isn’t just a one-size-fits-all plan. For example, some people need a certain type of plan that
covers more services than another plan. It’s important to understand the key differences between plans
so can avoid uncessary extra costs by seeking medical care outside the favorable terms of a particular
Fee-for-service Plans
Fee-for-service plans are a straightforward type of coverage in which insurers pay for health care services
provided to plan participants. With this type of coverage, you can choose any doctor you wish and change
doctors any time or go to any hospital in any part of the country.
Health Maintenance Organizations (HMO)
HMOs are a type of health insurance plan that usually limits coverage to care from doctors who work for
or contract with the HMO. Premiums are paid monthly, and a small copay is due for each office visit and
hospital stay. HMOs generally won’t cover out-of-network care except in an emergency. An HMO may
require you to live or work in its service area to be eligible for coverage.
HMOs also require that you select a primary care physician who is responsible for managing and
coordinating all of your health care. Your primary care physician will provide all of your basic health care
services, and must give a referral in order for you to see a specialist.
HMOs often provide integrated care and focus on prevention and wellness. HMO plans sometimes
include dental and vision coverage.
Preferred Provider Organization (PPO)
PPOs are similar to HMOs in that health care providers enter into an agreement with the insurance
companies to offer substantially discounted fees for covered health care services. Your copay and
deductibles will also be lower if you choose a provider that is in the PPO network. The payment ratio
(what your insurance company pays compared to what you pay) may be high for a PPO plan—for
example, it could be in the range of 90/10, with 90 percent of medical costs paid by the insurance
company and 10 percent covered by the insured after the copay and deductible.
With a PPO, you do not have to choose a primary care physician—you can choose doctors, hospitals and
other providers from the PPO network or from out of network. If you want to stick with a particular doctor
or health care provider that is out of network, you are able to do so, but the costs will be higher, generally
with a 70/30 ratio.
PPO plans typically include preventive care, wellness programs, immunizations, well-baby care and
mammograms, along with regular doctor visits, emergency care, specialist treatments, X-rays, hospital
stays, surgery and other medical services. PPOs also use a membership card instead of requiring
medical insurance claim forms for payment processing.
Exclusive Provider Organization (EPO)
An EPO is similar to a PPO in structure and operation, with the main difference being that services are
covered only if you go to doctors, specialists or hospitals in the plan’s network, although there are
exceptions for emergencies.
Point of Service Plan (POS)
POS plans combine elements of both HMO and PPO plans. Like an HMO plan, you may be required to
designate a primary care physician who will then make referrals to network specialists when needed.
Depending on the plan, services rendered by your primary care physician are typically not subject to a
deductible, and preventive care benefits are usually included. Like a PPO plan, you may receive care
from non-network providers but with greater out-of-pocket costs.
High Deductible Health Plan (HDHP)
HDHPs are health plans with high deductibles and low premiums, in which the insurer will not cover most
medical expenses until the deductible is met. As an exception, preventive care services are typically
covered before the deductible is met. The high deductible provides financial security for more severe
illnesses. HDHPs are often designed to be compatible with heath savings accounts (HSAs). HSAs are
tax-advantaged accounts that can be used to pay for qualified out-of-pocket medical expenses before the
HDHP’s deductible is met. These expenses can include copayments and coinsurance.
In 2014, for HSA-compatible HDHPs, the minimum deductible amounts remained the same at $1,250 for
an individual and $2,500 for a family, while the maximum out-of-pocket expenses increased to $6,350 for
an individual and $12,700 for a family.
Tax-advantaged Health Accounts
Tax-advantaged accounts are a type of medical savings vehicle that help individuals pay for qualified
medical expenses. They are often paired with HDHPs. There are specific rules for each type of account,
such as how much can be contributed and what the account’s funds can be used for. Many of these
accounts are employer-based, but people with individual insurance plans can take advantage of health
savings accounts provided they meet eligibility criteria.
Health Savings Account (HSA)
HSAs are available to people who are enrolled in an HSA-compliant HDHP. The account is individual owned,
and money may be contributed by the owner of the account or a dependent.
The funds contributed to the account are pre-tax, which means they aren’t subject to federal income tax at
the time of deposit. Funds must be used to pay for qualified medical expenses; there is a heavy tax
penalty for paying for non-qualified expenses. Funds roll over year to year if you don’t spend them, and
can accumulate a significant balance. There is a limit to how much money can be put into an HSA every
year, but no cap on how much money can be in the account.
Other Types of Insurance
Aside from standard health insurance, there are many other types of health related benefits an individual
can procure to assist with various aspects of health and wellness. Some of the most common examples
are listed below:
Prescription Insurance
Prescription insurance, sometimes called prescription drug coverage, helps pay for prescription drugs and
medications. Prescription insurance is often offered as part a larger health insurance plan, though this is
not always the case. Stand-alone individual prescription insurance may be available for people who are
not offered prescription drug coverage or who have no health insurance. Eligibility for specific medications
and the cost of insurance varies among health plans.
Dental Insurance
Dental insurance helps pay for dental care and usually includes regular checkups, cleanings, X-rays and
certain services required to promote general dental health. Some plans will provide broader coverage
than others, and some will require a greater financial contribution from you when services are rendered.
Some plans may also provide coverage for certain types of oral surgery, dental implants or orthodontia.
Vision Insurance
Vision insurance entitles you to specific eye care benefits defined in the policy. Vision insurance policies
typically cover routine eye exams and other procedures, and provide specified dollar amounts or
discounts for the purchase of eyeglasses and contact lenses. Some vision insurance policies also offer
discounts on refractive surgery.
Life Insurance
Life insurance protects against financial hardship after the death of the insured by paying out a lump sum
to beneficiaries upon the insured’s death. Term life insurance offers policies that cover a set period of
time, while permanent life insurance, such as whole and universal life, provides lifetime coverage. Death
benefits from all types of life insurance are generally free from income tax.
Disability Insurance
Disability insurance protects the insured against disability. With disability insurance, you are awarded a
disability benefit as a partial replacement of income lost due to illness or injury.
There are two types of disability insurance: short-term and long-term. Short-term disability insurance
(STD) helps you remain financially stable if you become injured or ill and cannot work. Usually, STD
coverage begins within one to 15 days of the event that caused your disability. The coverage allows you
to continue to receive pay at a fixed weekly amount or a set percentage of your income. The benefits can
last up to 52 weeks, although the amount of time you receive STD benefits varies between specific plans.
When this STD coverage ends, long-term disability (LTD) coverage typically takes effect.
LTD insurance protects workers if they become disabled for a prolonged period prior to retirement. The
length of LTD plans varies—some may be limited to a period between two and 10 years, while other
plans continue paying out until age 65.
