Can I Get Health Insurance Outside of My Job?

While many obtain health benefits through employers, it is possible to acquire health insurance outside of a job. This need often arises during career transitions, self-employment, or part-time work. This guide outlines pathways to individual health coverage and the financial considerations involved.

Primary Pathways to Individual Health Coverage

Individuals have several established avenues for obtaining health insurance when employer-sponsored plans are not an option. Each pathway offers distinct characteristics regarding eligibility, coverage, and cost structures.

One prominent option is the Health Insurance Marketplace, established under the Affordable Care Act (ACA). This platform allows individuals to compare and purchase health insurance plans that meet specific standards for comprehensive coverage, including preventive care, prescription drugs, and mental health services.

Government-sponsored programs also provide coverage for eligible individuals and families. Medicaid offers low-cost or free health coverage based on income and family size. The Children’s Health Insurance Program (CHIP) provides low-cost health coverage for children in families who earn too much for Medicaid but cannot afford private insurance.

Medicare is another government program, primarily serving individuals aged 65 or older and certain younger people with disabilities. It consists of different parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage through private plans), and Part D (prescription drug coverage). Eligibility is typically tied to age or specific health conditions.

Individuals can also purchase health insurance directly from private insurance companies. These plans generally do not qualify for financial assistance or subsidies available through the Health Insurance Marketplace. Direct comparison with insurers can be useful for those not qualifying for subsidies or preferring specific plan features.

For those transitioning from employer-sponsored coverage, the Consolidated Omnibus Budget Reconciliation Act (COBRA) provides a temporary option. COBRA allows eligible individuals to continue their group health benefits after leaving employment or experiencing other qualifying events. COBRA can be more expensive as individuals typically pay the entire premium, including an administrative fee. Coverage generally lasts for 18 months, though some beneficiaries may be eligible for up to 36 months.

Other options exist for temporary or specific situations. Short-term health insurance plans offer a temporary solution, often for less than a year, to bridge coverage gaps. These plans are not required to comply with ACA regulations, meaning they may not cover essential health benefits, can deny coverage based on pre-existing conditions, or impose annual limits. Another possibility involves joining a spouse’s or parent’s health plan, with adult children typically eligible to remain on a parent’s plan until age 26.

Financial Assistance and Enrollment Periods

Accessing health insurance outside of an employer involves understanding available financial assistance and specific enrollment timelines.

Premium Tax Credits (PTC)

Premium Tax Credits (PTC) are financial assistance that reduces the monthly cost of health insurance premiums purchased through the Health Insurance Marketplace. Eligibility is based on household income relative to the federal poverty level (FPL) and not being offered affordable employer coverage. For 2025, individuals and families with incomes at or above the FPL are generally eligible, with no maximum income limit through the end of 2025.

Cost-Sharing Reductions (CSRs)

Cost-Sharing Reductions (CSRs) further reduce out-of-pocket costs such as deductibles, copayments, and coinsurance. These reductions are available to eligible individuals who enroll in a Silver-level plan through the Marketplace.

Enrollment Periods

Enrollment in a health plan typically occurs during specific periods. The Open Enrollment Period (OEP) is an annual window when most individuals can enroll in a new health plan or change existing ones. For Affordable Care Act (ACA) plans, OEP generally runs from November 1 through January 15 in most states. To ensure coverage begins on January 1, enrollment usually needs to be completed by December 15.

Special Enrollment Period (SEP)

Outside of the Open Enrollment Period, a Special Enrollment Period (SEP) allows individuals to enroll in coverage due to qualifying life events. Common qualifying life events include losing existing health coverage, such as job-based insurance, turning 26 and aging off a parent’s plan, or losing eligibility for programs like Medicaid. Household changes, such as getting married, getting divorced, having a baby, or adopting a child, also trigger an SEP. Moving to a new ZIP code or county where new health plans become available can also qualify an individual for an SEP. Individuals generally have 60 days following a qualifying event to enroll in a new plan.

Evaluating Plan Details and Coverage

Once individuals understand their coverage options and potential financial assistance, the next step involves evaluating the specifics of available health plans.

Financial Aspects

Understanding a health plan’s financial aspects is important. The premium is the fixed monthly payment to maintain coverage. The deductible is the amount an individual must pay for covered services before the plan begins to pay. After the deductible is met, copayments are fixed amounts for specific services, and coinsurance is a percentage of the cost of covered services. The out-of-pocket maximum is the most an individual will pay for covered services in a plan year, protecting against high medical expenses.

Different types of health plans

Different types of health plans offer varying structures for accessing care.

Health Maintenance Organizations (HMOs)

HMOs typically require members to choose a primary care physician (PCP) who coordinates all care and provides referrals to specialists.

Preferred Provider Organizations (PPOs)

PPOs offer more flexibility, allowing members to see any provider, though costs are lower when using in-network providers, and referrals are generally not required.

Exclusive Provider Organizations (EPOs)

EPOs combine features of HMOs and PPOs, often not requiring referrals but limiting coverage to providers within the plan’s network, except in emergencies.

Point of Service (POS) Plans

POS plans blend features of HMOs and PPOs, offering a choice between in-network, coordinated care and out-of-network care at a higher cost.

A plan’s provider network

A plan’s provider network is a significant consideration. Verify that preferred doctors, specialists, and hospitals are included as “in-network” providers to avoid higher out-of-pocket costs. Using out-of-network providers can result in substantially higher fees or no coverage, depending on the plan type.

Prescription drug coverage

Prescription drug coverage requires careful review. Check the plan’s formulary, a list of covered medications, to ensure necessary prescriptions are included and to understand their cost-sharing.

Essential Health Benefits (EHBs)

All plans purchased through the Health Insurance Marketplace and most other individual plans are required to cover Essential Health Benefits (EHBs). These 10 categories of services include:
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care