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How is individual insurance different from group insurance?

Individual health insurance is, quite simply, coverage that an individual purchases for himself and/or his family. The Affordable Care Act (ACA) has made significant changes to how individual insurance policies are rated and the benefits that these policies provide. Individual policies are often purchased with the advice of a professional insurance producer due to the complexity of coverage offerings and the premium cost. With the advent of the ACA, a professional insurance producer's expertise may be even more critical since insurance policies have changed so dramatically.

Our Agency offers the following individual plans:

  • Tradition and Deductible Medical Plans
  • Consumer-Directed Health Plans (HRA, HSA & Flexible Spending Accounts)
  • PPC, Point of Service & Out-of-Area Health Plans
  • Dental & Vision Plans
  • Life Plans
  • Disability & Income Replacement Plans
  • Long Term Care

Whether or not a person has a pre-existing medical condition is no longer a factor when purchasing individual coverage. Since a person's medical condition is not a factor, individuals are limited to certain times when they can enroll in coverage. A person must enroll during an open enrollment period to gain coverage for the year. There are limited opportunities to purchase coverage at other times during the year as a result of a special enrollment right.

Individual insurane policies in 2014 may be purchased through an exchange or "marketplace" or they may be purchased outside of the exchange. Irrespective of whether a policy is purchased inside or outside the exchange, policies must cover the same set of Essential Health Benefits. The richness of the benefits under the plan is defined by a metal tier. These tiers are based on the percentage the plan pays of the average overall cost of providing essential health benefits to members:

  • Platinum plans are the most generous and more expensive. These are designed to pay as much as 90% of medical expenses
  • Gold plans are designed to pay 80% of medical expenses
  • Silver plans are expected to pay 70% of medical expenses
  • Bronze plans are expected to pay 60% of medical expenses

Health insurance plans offered through the exchange or outside of the exchange will offer the same essential health benefits. Each plan or insurance company may add items or services to these minimum essential benefits and may vary the hospitals and doctors that are part of the network so it is important to compare plans.

The essential health benefits include:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services
  • Prescription drugs
  • Laboratory services
  • Preventive and wellness services
  • Pediatric services
  • Rehabilitative and habilitative services and devices

 

 

 

 

 

 

 

 

 

 

   
   
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