Individual and Family
Health Insurance Benefits Covered by Individual and Family Plans
Published on August 27, 2014
Individual and family plans offer affordable health insurance benefits to the over 13 million people in the United States who can’t get insurance through their employer.
Individual and family plans offer coverage to unemployed and self-employed people, students, people between jobs, and retirees who aren’t yet eligible for Medicare health insurance benefits.
Under the Affordable Care Act (ACA), also known as Obamacare, individual and family plans are now sold through private, federal, and state online insurance exchanges. And, as before, they are also sold by brokers and insurance companies.
Public health insurance exchanges also let you apply for a government subsidy, Medicaid, or the Children’s Health Insurance Program (CHIP), so you can get help paying for your health plan if you qualify.
Benefits offered by individual and family plans
Individual and family plans vary from state to state, but all include certain core health insurance benefits required by the ACA.All plans are now required to offer you the following minimum essential coverage.
Standard of care: Medical plans must cover preventive services without copayments, deductibles, or coinsurance requirements. You can choose your own doctors within their networks but seek emergency care at any hospital.
Preventive care: Health plans must also include:
- Immunizations recommended by the Centers for Disease Control and Prevention (CDC) for children, adolescents, and adults
- Preventive care recommended by the Health Resources and Services Administration (HRSA)
- Services with an “A” or “B” rating according to classifications made by the United States Preventive Services Task Force (USPSTF)
- Certain women’s services and screenings
Limits of costs: The maximum out-of-pocket yearly expense for an individual in 2014 is $6,350 and for a family is $12,700. These limits include all deductibles, copayments, and coinsurance costs. Plans can’t limit lifetime insurance payouts, and any yearly premium increases are reviewed for fairness.
Your additional rights under the ACA
Under the ACA, you can no longer be denied health insurance for pre-existing conditions or have your insurance canceled because of any honest mistakes you make. This means people who formerly didn’t qualify for coverage or had to pay more (those who were pregnant or had diabetes, heart disease, high blood pressure, and other conditions) are now covered.
You have the right to appeal any routine denial of payment. Young adults can continue to receive coverage under their parents’ family plan until reaching age 26.
When to enroll in individual and family health plans
The Open Enrollment Period for plans with coverage starting in 2015 begins on November 15, 2014. However, you and your family may qualify for a special enrollment period, if you experience a major life change (called a qualifying life event) outside of open enrollment; but you must enroll or make a change to your health plan within 60 days of the qualifying event.
Medicaid and CHIP are available all year to provide coverage to low-income families. Alaska Native shareholders and other federally recognized tribes may enroll in marketplace plans year round.
Be aware that, beginning in 2014, you can face tax penalties for not having health insurance coverage or for having a gap of more than three consecutive months.
Health insurance helps you and your family get coverage to suit your needs and budget. Get ready for this year’s Open Enrollment Period with eHealth: Review the individual and family plans you may qualify for now.