Do you have health insurance? If not, you might be putting your finances at risk if you become sick or injured. Before you enroll in a plan, use Benzinga’s guide to understand how health insurance in Vermont works and where you can get coverage.
The Best Health Insurance in Vermont:
- Best Overall in Vermont: BCBS of Vermont
- Most Affordable in VT: MVP Health
- Best for Combining Coverage: Cigna
- Best Vision Insurance: VSP
- Best Dental Insurance in Vermont: Delta Dental
What is Health Insurance?
Health insurance financially protects you if you get sick, need surgery or are involved in an accident. Without health insurance, medical bills can quickly total hundreds of thousands of dollars. You’ll no longer face a tax penalty for not having health insurance but it’s always a good idea to have some form of coverage.
Most people get their health insurance through their employers. If you’re over the age of 65 or you have a disability, you might get your insurance through Medicare. You may qualify for Medicaid if you live in a very low-income household. If none of the above situations apply to you, you can still buy coverage through the Affordable Care Act (ACA) Marketplace, which operates in every state.
When you shop for ACA plans, you might see a number of different prices and numbers listed. It can be difficult to understand exactly how much you’ll pay for your coverage if this is your first time shopping. First, let’s go over the basic insurance structure in the U.S. before we go over the specific types of plans you’ll see.
Premiums & Deductibles
Every month, you must pay your health insurance provider a premium. Your monthly premium keeps your coverage current and is due even if you don’t use your benefits in a given month. Let’s say you do use your benefits. First, you’ll need to meet your deductible before your insurance covers you. Before you meet your deductible, you must pay 100% of your medical care costs.
Once you meet your deductible, you only need to cover your coinsurance percentage. Your coinsurance is the percentage of your care costs that you need to pay after your deductible. For example, let’s say you have a plan with a 20% coinsurance rate and you get a bill for $1,000 of medical care. Assuming you’ve met your deductible, you’d pay $200 toward this bill and your insurance provider would cover the remaining $800.
This continues until you meet your out-of-pocket maximum, which is the maximum amount you will spend on your insurance in a given year. Once you meet your out-of-pocket maximum, your insurance covers 100% of your medical care costs.
Average Cost of Health Insurance in Vermont
Vermont has some of the most expensive independent health insurance options in the United States. The average individual pays about $524 per month for coverage.
If you have a lower income but you don’t qualify for Medicaid, you might qualify for a subsidy through the ACA Marketplace. Subsidies lower the cost of your premium and make health insurance more affordable. To learn if you qualify, visit Healthcare.gov and create a profile.
Types of Health Coverage
One of the first things you’ll need to choose when you shop for health insurance is your plan type. There are a few different types of health insurance plans, and the specific plans you’ll see on the Marketplace will depend on the company’s offering and your ZIP code. Some of the most common types of plans you’ll run into include:
- Health maintenance organizations (HMOs): HMO plans are typically the most affordable health insurance option you’ll see when you shop. However, they also give you the least amount of freedom to use your benefits. When you sign onto your HMO plan, your insurance provider will give you a list of in-network care providers. You can only see care providers in your network. If you go out of your network, you can’t use your insurance — you’ll need to cover all of your care costs out of pocket. You also need a primary care provider’s referral to see a specialist.
- Preferred provider organization (PPO): You can see any doctor or specialist you want with a PPO plan. Most PPO plans still have networks, and you’ll usually pay less if you see an in-network health care provider. However, you can use your benefits outside of your network and you usually don’t need a referral to see a specialist. PPO plans cost more than HMOs, but they can be useful if you have a particular care provider you want to keep seeing.
- Point-of-service (POS) plans: You can see any doctor you want and still use your benefits with a POS plan but you’ll need to get a referral to see a specialist. POS plans were created to balance costs and coverage, but not every provider offers them.
What Does Health Insurance Cover?
Your plan must cover a set number of essential benefits if you buy an ACA-compliant plan through Vermont’s health insurance Marketplace. Some things that your plan must cover include:
- Ambulatory patient services: This is the care that you receive outside of a hospital.
- Emergency services: Your plan needs to cover emergency services and care, including trips to any emergency room. Your plan cannot deny you coverage for visiting an out-of-network ER in an emergency situation.
- Hospitalization: This includes things like emergency overnight stays and surgeries.
- Mental health and substance abuse disorder treatments: This type of care includes treatments like psychotherapy for mental disorders and inpatient treatment for addiction.
- Rehabilitative and habilitative services: This includes treatments for mobility after an accident. It also includes devices intended to help with mobility, like crutches or a wheelchair.
- Prescription drugs: Your insurance provider must offer some form of coverage for all classes of prescription drugs but it doesn’t need to cover specific drugs. If you already take a prescription drug, it’s a good idea to search for insurance providers who cover the drug you’re taking.
- Maternity and post-maternity care: This type of care includes all the services you need before and after delivery, including breastfeeding support and newborn care.
- Preventive services: This includes things like annual checkups and chronic disease management.
- Laboratory services: Lab services include tests like bloodwork, lipid panels and STD testing.
- Pediatric services: Your insurance provider must cover all of the benefits seen above for any children on your plan. It must also cover dental and vision care for children.
If you’re female, your insurance provider must also include coverage for birth control. This coverage must extend to hormonal methods (like the ring and the pill), physical methods (like diaphragms) and emergency contraceptives (like Plan B).
What Does Health Insurance not Cover?
No matter what, there are some things that no insurance provider covers. Some common exclusions you’ll see include:
- Travel vaccinations: Your insurance provider needs to cover “routine and necessary” vaccines. However, plans aren’t required to cover vaccinations if you’re taking a trip to a country where non-routine vaccinations are required. You’ll need to cover them out of pocket.
- Male birth control: The ACA only requires that insurance companies cover female methods of birth control. Few insurance providers cover male methods, like condoms and vasectomies.
- Weight-loss surgeries: There is no federal requirement that forces insurance companies to cover bariatric surgery. However, some plans do elect to include this coverage.
- Cosmetic surgery: Insurance providers only cover reconstructive surgery if it’s medically necessary.
- Adult dental and vision services: Insurance providers aren’t required to cover adult dental or vision services. However, you can add on a separate dental or vision plan with its own deductible.
Best Health Insurance Providers in Vermont
You now know everything you need to know to enroll in a plan in Vermont. Let’s take a look at some of the best health insurance plans you’ll see on the ACA Marketplace and beyond.
- Nationwide coverage
1. Blue Cross Blue Shield of Vermont
Blue Cross Blue Shield of Vermont is one of the largest individual and family health insurance providers. Its team offers a wide variety of plans, which can help you balance your premium and deductible expenses to fit your budget.
Most plans also include $0 coinsurance after you meet your deductible, and full-service ACA plans are available from $545 per month for individuals. When you have a Blue Cross Blue Shield plan, you’ll also gain access to its online wellness portal, which includes tips and discounts you can use to improve your health.
2. MVP Health
MVP Health is another individual and family plan provider that offers ACA-approved plans on the Marketplace. You can find multiple tiered plans from MVP, which can help you control the balance between what you’ll pay in an annual deductible versus your monthly premium.
Plans from MVP Health also have lower coinsurance and copays than you’re likely to find on competing short term health insurance plans.
With a wide variety of plans and clearly laid-out benefits, MVP Health might be the right insurance provider for you if you don’t mind spending some time comparing your choices.
Best Dental and Vision Insurance Providers in Vermont
Adult dental and vision insurance isn’t included in most ACA-compliant plans. If you want to get additional coverage for adults on your plan, consider one of these top providers.
- Easy access to benefits
1. Cigna
Cigna offers affordable and comprehensive dental insurance plans throughout Vermont. Coverage is available in most parts of the state from just $17 a month. All of its plans include 100% coverage for preventive dental care, including X-rays, exams and routine cleanings.
Deductibles on Cigna plans are also exceptionally low — you’ll pay just $50 a year on an individual plan and $150 a year on a family plan. Cigna is one of the most popular complementary dental insurance policy providers from over 15 million policyholders across the United States.
- Top-rated vision insurance
2. VSP Vision Care
VSP Vision Care is one of the largest nonprofit vision insurance companies in Vermont with a network of over 26,000 doctors’ offices across the country.
Consistently highly rated by J.D. Power & Associates, VSP Vision Care is one of the country's top choices for companies who value quality customer service and easy-to-understand plan choices.
VSP offers a range of plans available from just $13 a month if you’re retired or self-employed. VSP Vision Care is a quick and convenient option for anyone looking for vision coverage in Vermont.
- Cleaning + exams
3. Delta Dental
Delta Dental is a nonprofit dental insurance provider that offers affordable dental coverage in Vermont for individuals, families and business owners. Plans for individuals are available from just $27 a month in most parts of Vermont and provide comprehensive coverage choices.
You can choose from up to 5 different plan tiers in most ZIP codes — an asset for anyone looking to balance costs and coverage. Delta Dental also offers low-cost group plans as well if you run a small business and you’re looking for coverage for your employees.
Protect Your Health with the Right Coverage in Vermont
Figuring out how to get health insurance outside of an employer-sponsored plan can be difficult. Start by signing up for a profile at Healthcare.gov. Healthcare.gov is the official ACA Marketplace website. It’s a great place to begin your search for the right coverage. Just enter a little personal information and the website will direct you to your state’s exchange to view specific plan options available to you.
About Sarah Horvath
Sarah is an expert in the insurance, investing for retirement and cryptocurrency space.