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Open Enrollment for 2021 is quickly approaching. If you need to switch your health insurance plan or purchase a new plan, you should know what to expect when Open Enrollment arrives.
Our guide to individual and family health insurance plans will help you understand what health insurance does and doesn’t cover and where you can find the best plan for your needs.
Best Health Insurance Options
Where you live will determine which health insurance companies offer plans in your area. There are dozens of regional health insurance companies that offer affordable health insurance plans throughout the country.
Begin your search by collecting a few quotes from a few of our favorite providers below.
How Open Enrollment Works
Open Enrollment is the annual period during which you can enroll in a new health insurance plan for the coming year. If you’re an employee eligible for insurance through your employer, Open Enrollment is the period during which you can sign onto your company’s insurance policy or switch to a different policy. Though you can usually drop your coverage at any point in the year, you may only sign onto a new plan during the Open Enrollment window.
If you’re self-employed, you can use the Open Enrollment period to browse policies available to you on the Affordable Care Act (ACA) Marketplace. When the Open Enrollment period arrives, visit Healthcare.gov and complete a profile detailing your location, age and insurance needs. You’ll be directed to your state’s exchange and explore plan options open to you. From here, you can sign up for a new plan directly through the exchange or by contacting 1 of the insurance providers offering plans in your state.
Open Enrollment Periods
In most states, general Open Enrollment begins on November 1 and closes on December 15. Some states with their own exchanges offer more flexible enrollment periods. The plan you purchase during Open Enrollment will go into effect on January 1 of the following year. For example, if you sign up for a new health insurance plan on December 10, 2020, your coverage doesn’t actually begin until January 1, 2021.
What if you lose your health insurance coverage or need to change your plan outside of the Open Enrollment period? If you lose coverage, you may qualify for a Special Enrollment period. When a Special Enrollment period is triggered, you can access the ACA Marketplace outside of the standard Open Enrollment period. Some qualifying life events that may trigger a special enrollment period include:
- Changes in your household. You may qualify for a Special Enrollment period if you’ve gotten married, given birth or adopted a child, gotten a divorce or undergone the death of a spouse in the last 60 days.
- Changes in your residence. If you move outside of your zip code or from transitional to permanent housing, you’ll qualify for a Special Enrollment period.
- Loss of coverage. If you or anyone in your household has lost coverage within the past 60 days or anticipates losing coverage in the next 60 days, you may qualify for a Special Enrollment period. Examples of valid loss-of-coverage reasons include turning 26 and being removed from your parent’s insurance or losing your job.
- Other qualifying life events. Leaving incarceration, gaining residency or citizenship status or gaining membership in a federally-recognized tribe may all qualify you for a Special Enrollment period.
The Average Cost of Health Insurance
Where you live, your age and whether or not you smoke will all play a role in the price you’ll pay for health insurance. Older men and women and smokers tend to pay more for insurance because they are more likely to encounter an expensive health issue that requires the use of their insurance.
The average monthly premium for health insurance for an individual falls into these average ranges:
- Under 18 years of age: around $150 per month
- 18 to 24 years of age: around $180 per month
- 25 to 34 years of age: around $240 per month
- 35 to 44 years of age: around $300 per month
- 45 to 54 years of age: around $400 per month
- 55 to 64 years of age: around $580 per month
You may qualify for a government subsidy to lower your health insurance expenses if you meet income standards. When you complete your profile at Healthcare.gov, the system will automatically inform you if you qualify for a subsidy.
What Does Health Insurance Typically Cover?
Thanks to the introduction of the Affordable Care Act, any health insurance plan that you purchase on the Marketplace must include certain benefits. These “essential benefits” include:
- Ambulatory patient services. This includes any type of outpatient care that you receive outside of a hospital. A visit to a dermatologist’s office to remove a dangerous mole is an example of an ambulatory patient service.
- Emergency services. Your insurance provider is required to cover emergency medical services. In the event of an emergency, you should always visit the hospital nearest to you, regardless of your plan or network. It’s against the law for your health insurance provider to require you to contact them or to use a specific hospital or network during a medical emergency.
- Hospitalization. This includes overnight stays at the hospital and both urgent and planned medical surgeries.
- Mental health and substance abuse treatment. Your insurance must cover both inpatient and outpatient mental health services.
- Prescription drugs. Your insurance provider must provide some form of coverage for all major classes of prescription drugs. However, insurance providers aren’t required to cover every individual prescription on the market. If you’re already taking a particular prescription medication, you can search for specific health insurance plans that cover it in the Marketplace.
- Rehabilitative and habilitative services. This includes services like physical therapy and devices to help you regain physical or mental capacities after an injury (for example, a wheelchair).
- Pregnancy, maternity and newborn care. This requirement extends throughout your pregnancy and after you give birth.
- Laboratory services. This includes specialized lab tests like x-rays or mammograms.
- Preventative and wellness services. This includes services like annual physicals, ongoing treatments for chronic conditions, routine blood work and more.
- Pediatric services. Your insurance must cover all of the above treatments and services for any child enrolled on your plan. Insurance providers are also required to provide dental and vision care for children on your plan as well — though this isn’t a legal requirement for adults.
- Birth control. If you’re a woman, your health insurance plan must cover all forms of FDA-approved contraceptives, including hormonal, implanted, physical and emergency forms of birth control. Though some employers may not be required to provide this coverage, all plans sold on the ACA Marketplace must.
These essential benefits are the bare minimum requirements for Marketplace insurance plans. Your specific plan may or may not include additional benefits like dental insurance.
Keep in mind: these required benefits only extend to long-term health insurance plans purchased through the ACA Marketplace. If you purchase a short-term health insurance plan, you are not guaranteed these benefits.
Short-term health insurance options are not required to comply with ACA standards. Many short-term insurance plans engage in practices now illegal for ACA-compliant plans, including:
- Limiting or denying coverage for pregnancy, prescriptions and mental health services
- Limiting or denying coverage based on a pre-existing condition
- Requiring a medical questionnaire before calculating your deductible and premium
- Instituting an annual or lifetime limitation on the total amount of money that you can claim from your insurer after an accident or diagnosis
If you do decide to purchase a short-term health insurance plan, be 100% certain you completely understand what the plan does and does not cover.
What Does Health Insurance Not Cover?
Many health insurance plans only provide coverage for the legally required essential benefits listed above. Some examples of services that may not be included on your plan include:
- Adult dental and vision services. Health insurance providers are only required to provide dental and vision coverage for children on your plan. There is no federal requirement that insurance providers extend these services to adults included on your plan — though some insurance providers elect to offer this voluntarily.
- Travel vaccinations. Health insurance companies must extend coverage to the Center for Disease Control’s (CDC) list of standard vaccinations. If you need a special vaccination before travel (such as the Yellow Fever or Typhoid vaccines) you’ll typically need to pay for it out-of-pocket.
- Cosmetic procedures. No health insurance plan will cover the cost of surgery that is not medically necessary.
- Male birth control. The Affordable Care Act’s birth control mandate only extends to females included on the insurance plan. Most health insurance plans will not cover the cost of male birth control, including condoms and vasectomies.
- Nursing home care. Though health insurance does cover short-term stays in skilled nursing facilities following an accident, long-term stays in nursing facilities are not usually covered by insurance. If you want to ensure that you have protection should you need to move into a long-term care facility, you may want to consider purchasing a separate long-term care insurance plan.
- LASIK surgery. Because LASIK is considered to be an elective procedure, it is not usually covered by health insurance.
Find the Right Health Insurance Plan
Still learning how to get health insurance for 2021? Find the right plan begins by comparing multiple quotes from competing insurance providers in your area. Start by exploring a few of your options here at Benzinga — simply enter your ZIP code and receive your customized quote.