Individual Health Insurance Made Simple

• 60 days from the date of the qualifying event (in most cases).

• Loss of other health coverage (job-based, Medicaid, etc.)
• Marriage or divorce
• Birth or adoption of a child
• Moving to a new ZIP code or county
• Gaining U.S. citizenship or lawful presence
• Leaving incarceration
• Change in immigration status
• Changes in income affecting eligibility for subsidies
  

1. Covers 10 essential health benefits, including:

• Doctor visits
• Emergency services
• Hospitalization
• Prescription drugs
• Maternity and newborn care
• Mental health services
• Preventive services (like vaccines and screenings)

    2. No denial for pre-existing conditions

    3. No annual or lifetime limits on essential health benefits

    4. Free preventive care (check-ups, screenings, immunizations)

    5. Subsidies available:

• Based on your income, you may qualify for premium tax credits or cost-sharing reductions to make the plan more affordable.

A tax credit for health insurance — usually called the Premium Tax Credit (PTC) — is financial help from the government that lowers the cost of health insurance premiums if you buy coverage through the Affordable Care Act (ACA) marketplace. It’s a subsidy based on your income and household size that helps you pay for a health insurance plan. Certain qualifications vary.

HMO (Health Maintenance Organization)

• Primary Care Physician (PCP) required: You must choose a PCP who coordinates your care and gives you referrals to see specialists.
• Network only: Coverage is usually limited to doctors, hospitals, and providers within the HMO network (except emergencies).
• Lower costs: Typically has lower premiums and lower out-of-pocket costs than a PPO.
• Less flexibility: You can’t usually see out-of-network providers unless it’s an emergency.

PPO (Preferred Provider Organization)

• No referrals needed: You don’t need a PCP to access specialists. You can go directly to a specialist.
• In- and out-of-network coverage: You can see doctors both inside and outside the PPO network (though in-network is cheaper).
• Higher costs: Premiums and out-of-pocket costs are usually higher than HMOs.
• More flexibility: Greater freedom to choose providers, even out-of-network.

Short-Term Health Insurance

• Designed for temporary coverage (e.g., between jobs, waiting for Medicare).
• Can last a few months up to 364 days, and in some states renewable for 3 years.
• Typically excludes pre-existing conditions and has coverage limits.
• Usually cheaper, but less comprehensive.
• Not available in all states

Fixed Benefit Indemnity Plans

• Pay a set cash benefit per service (e.g., $200 per day in hospital, $50 per doctor visit).
• You can use the money toward bills, but it may not cover full costs.
• Doesn’t replace major medical insurance — more of a supplement.