Approximately half of US workers receive employer-sponsored health insurance (also called group health insurance). For them, most of the complicated coverage decisions are made by their employers as part of the benefits package.
If you own a small business, are self-employed, or are navigating a career change, finding the right health insurance can be considerably more complicated. In this article, we’ll discuss the options available to you if you fall under one of these categories.
There are three basic ways to get health insurance if not covered by an employer-sponsored plan:
The Consolidated Omnibus Budget Reconciliation Act (COBRA)
COBRA allows workers to continue health benefits from their group health plan for up to 18 months after a voluntary or involuntary job loss, reduction of working hours, death, divorce, and other major life events. Qualified individuals may be required to pay the entire premium for coverage up to 102% of the plan’s cost.
COBRA also requires that employers with 20 or more employees offer a temporary extension of health care coverage under certain situations when the plan would otherwise be finished.
Employers and carriers are required to provide employees with notice of discontinued coverage and their options to continue under COBRA.
Health Insurance Marketplace – Affordable Care Act (ACA)
ACA Marketplace health insurance plans are another option for those not covered under employer-sponsored plans. Enrollment for this coverage is limited to November 1st to December 15th unless you experience what is called a “qualifying life event.”
Choosing ACA health insurance allows more control over benefits, premiums, and out-of-pocket costs. You also cannot be denied coverage for pre-existing conditions.
Types of ACA Health Insurance Plans include:
- Health Maintenance Organization (HMO) plan for in-network physicians and referrals
- Exclusive Provider Organization (EPO) plans contract with doctors and hospitals to provide care to the health plan’s member
- Point of Service (POS) plan which is a hybrid of HMO & PPO coverage
- Preferred Provider Organization (PPO) plan that provides nationwide coverage
An individual can purchase a plan through their website, call centers, and in-person.
Small business owners are eligible to use the Small Business Health Options Program (SHOP) Marketplace to provide health insurance to their employees.
When applying for individual or family coverage through the Health Insurance Marketplace, you’ll provide details such as household income to determine if you’re qualified to receive:
- Tax credits and savings on your insurance to save more
- Medicaid and Children’s Health Insurance Program (CHIP) which varies by state
Private Health Insurance
Private health insurance is the most popular option next to employer-sponsored coverage. These policies are offered by private entities and are a great option for independent contractors, the self-employed, and small business owners.
Depending on your eligibility and pre-existing conditions, you have the choice of various private insurance plans:
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Exclusive Provider Organizations (EPOs)
- Point-of-Service (POS) Plans.
- High-Deductible Health Plans (HDHPs), which may be linked to health savings accounts (HSAs)
Health Maintenance Organization – HMO Plans
This insurance plan allows you to pick your primary care physician within your HMO network. All referrals for specialist visits and medical needs must be made within your HMO network or will be subject to additional costs. The only exception to this is if you need emergency healthcare.
Preferred Provider Organization – PPO Plans
This type of health insurance gives you an entire network of preferred healthcare providers. PPO plans are ideal for contractors and self-employed workers due to their flexibility and nationwide coverage.
With PPO insurance, you have the advantage of:
- Seeing a physician or healthcare provider of your choosing
- No need to choose a primary care physician(PCP)
- No referrals needed for specialist visits
- Greater flexibility than all other travel nursing coverage options
Exclusive Provider Organization – EPO Plans
An EPO is a type of health plan that falls somewhere between a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO) in terms of cost and flexibility. With an EPO, individuals have in-network coverage (except for emergencies), but they do not need to select a primary care physician (PCP) or get referrals to see specialists.
EPO health insurance members are covered for emergency care no matter where they are – in or out of network.
Point of Service – POS Plans
Individuals with a POS plan can still choose their Primary Care Physician, but more out-of-network healthcare providers are accessible. Their network is essentially larger than that of an HMO plan but smaller than a PPO. A portion of medical expenses outside the PPO network is covered.
POS plans can be as much as 50% cheaper but tend to be confusing to navigate. They can also take as long as 3-6 months for reimbursement after a health care visit.
High-Deductible Health Plans – HDHPs & Health Savings Accounts – HSAs
HDHP monthly premiums are usually lower, but an individual will pay more before the policy takes over. These plans are a good option for healthy individuals who only need coverage for serious ailments or emergencies.
HDHPs can also be combined with a health savings account (HSA), allowing you to pay for certain medical expenses with money exempt from federal taxes.
Our recommendations for those not covered by employer-sponsored healthcare
Overall, PPOs provide the freedom and flexibility that goes hand-in-hand with being self-employed. Everyone’s health care needs are unique, and talking to an expert is crucial while selecting the right policy for you and your family.
Simple Health Quotes has an experienced customer support team specializing in health insurance. We’ll guide you through the policy selection process from start to finish. After you choose the right plan, our staff remains available to you for the duration of your policy.