The world of health insurance can be overwhelming, with a variety of available plans, rules, and deadlines. Many people obtain health insurance through employer-provided coverage. But what can you do if you need—or choose—to get coverage outside of an employer?

It’s important to understand the differences in plans, what they provide, and their costs in order to get the coverage that makes the most sense for you or your family.

Health Insurance Options

Employer-Sponsored Insurance

Many employers offer health insurance plans for employees and their families. Your company will have already secured the relationship with the health insurance carriers/insurers, which means you will only have to choose a plan. This is often the most affordable and convenient option for many people. However, what if you don’t feel that this provider and plan are what best fit your needs—or your employer doesn’t offer insurance at all?

Public Health Insurance

If you need or choose to get coverage independent of your employer, you can purchase an individual health insurance plan on the state or federal marketplace or the private health insurance market. Depending on the size of your company, an individual plan will likely be more expensive than an employer-sponsored plan, but your options will be less limited. It won’t be tied to your current job, and you will have more control over choosing a company and plan that provide the benefits that best suit yourself or your family.

When/Where Can I Purchase Health Insurance?

Most private insurance can be purchased all year round, but public insurance is only available during the annual open enrollment period that runs from November 1st to January 15th. If you plan to enroll in public insurance, this is the most crucial time of the year for enrolling, changing, or renewing plans, so it’s important to be prepared to make a decision before the deadline. 

However, you may experience a major life event at any time of the year that causes you to require a change in insurance outside of open enrollment. These are called qualifying life events (QLE) and can make you eligible for a special enrollment period, which will allow you a window of time to make a change or purchase new insurance.

If you want to get coverage from your employer, you can usually enroll when you first begin the job. Some companies may have probation periods or qualifiers before you can opt in to the health insurance benefits. Otherwise, employers may have their own open enrollment period for employees to make changes or enroll. This is usually shorter than open enrollment through the marketplace and may take place at various times of the year. You can also use qualifying life events to gain coverage through your employer, make changes to your plan, or switch from employer to individual health insurance.

Depending on where you live, you will use either a state or the federal marketplace to purchase individual health insurance. To find your marketplace, visit HealthCare.gov and enter your location. If you’re not sure whether public or private insurance is right for you, you can work with an experienced health insurance advisor to guide you in the right direction. 

Understanding Health Insurance Plans

There are four main types of health insurance plans. They are:

• HMO (Health Maintenance Organization)
• PPO (Preferred Provider Organization)
• POS (Point of Service Plan)
• EPO (Exclusive Provider Organization)

It’s important to learn the benefits of each one to decide which best fits your specific situation.

HMO

An HMO utilizes its own network of healthcare providers and won’t cover out-of-network care at all, except in some emergencies. This will give you the least amount of freedom in choosing providers, but with the benefit of lower out-of-pocket costs. It requires a referral from your primary care provider to see specialists.

PPO

A PPO gives you more freedom in choosing providers, but out-of-pocket costs will be higher. It will cover visits to out-of-network providers, but it will be more expensive than in-network. It does not require a referral to see a specialist.

POS

A POS, similar to a PPO, gives more options for choosing a provider and allows you to see out-of-network doctors, though it will still be more expensive than in-network. However, unlike a PPO, a POS will require referrals to see specialists.

EPO

An EPO, like an HMO, has its own network of providers with lower out-of-pocket costs, and will not cover out-of-network care at all. However, unlike an HMO, you do not need a referral to see a specialist.

How to Pick a Health Insurance Plan

In order to pick a health insurance company and plan, you’ll have to consider a number of factors specific to you or your family’s lives. Are there any current or chronic health issues? Do you have ongoing prescriptions? Are you planning on having a baby? 

If you require frequent care or prescriptions, you may want to choose a plan with a higher premium—that’s your monthly cost for your health insurance plan. A plan with a higher premium will cover a larger amount of your medical bills and prescriptions, leaving you with a lower out-of-pocket cost. 

On the other hand, if you are generally healthy and do not foresee frequent doctor’s visits or prescriptions, it may be worth it to choose a plan with a lower premium. You will pay less each month for your plan, but with higher out-of-pocket costs if you do end up needing medical care.

It’s also important to consider a company’s network. These are the medical providers that your plan will allow you to see at a lower cost. Some have larger networks than others, giving you a wider range of available options. If you want to keep your current medical providers, you’ll want to look for plans that have them in-network. You should also make sure that your new plan has in-network providers that are close to your immediate location. 

How to Get Health Insurance Outside of Open Enrollment

If you find yourself needing insurance outside the open enrollment period, you have likely experienced a qualifying life event and are eligible for a special enrollment period. For more information about qualifying life events, visit my comprehensive guide here.

If you need health insurance but have not experienced a qualifying life event, you still have options to ensure you get the coverage you deserve. Schedule a consultation with me for personalized guidance on choosing quality health insurance.