Getting Health Insurance When Your Employer Doesn’t Offer It

For individuals whose employers do not provide health insurance, understanding available options is important for securing medical coverage. Health insurance helps protect individuals and families from high costs associated with medical care.

Understanding Your Health Insurance Options

Understanding common terms is helpful before exploring health insurance options. The “premium” is the fixed amount paid, typically monthly, to maintain health insurance coverage.

Beyond the premium, other costs are incurred when receiving medical services. A “deductible” is the specific dollar amount an insured person must pay for covered medical services each year before their insurance plan contributes to costs, excluding preventive care.

After the deductible is met, “co-pay” and “co-insurance” apply. A “co-pay” is a fixed fee paid at the time of service, such as for a doctor’s visit or prescription. “Co-insurance” is a percentage of the cost of a covered service paid by the insured after the deductible has been satisfied. For instance, if a plan has 20% co-insurance, the insured pays 20% of the bill, and the insurer covers the remaining 80%.

The “out-of-pocket maximum” represents the highest amount an individual will pay for covered medical services in a year, including deductibles, co-pays, and co-insurance. Once this maximum is reached, the insurance plan typically covers 100% of additional covered medical costs for the remainder of the year.

Government-Sponsored and Subsidized Health Coverage

The Affordable Care Act (ACA) established Health Insurance Marketplaces for individuals without employer-sponsored plans or eligibility for Medicare or Medicaid. These Marketplaces offer various health plans categorized by “metal levels”: Bronze, Silver, Gold, and Platinum. These categories indicate how costs are shared between the plan and the individual, not the quality of care. Bronze plans generally have the lowest monthly premiums but higher out-of-pocket costs when care is needed, while Platinum plans feature the highest premiums but the lowest costs at the time of service.

The ACA Marketplace offers financial assistance to make coverage more affordable. Two primary types of subsidies exist: Advanced Premium Tax Credits (APTCs) and Cost-Sharing Reductions (CSRs). APTCs lower monthly premium payments based on income, household size, and local coverage costs. They can be applied directly to the premium. Eligibility for APTCs applies to U.S. citizens and legal residents with incomes at or above 100% of the Federal Poverty Level (FPL). The Inflation Reduction Act of 2022 extended enhanced subsidies through 2025, ensuring most individuals pay no more than 8.5% of their income for premiums.

Cost-Sharing Reductions provide additional savings by lowering out-of-pocket costs such as deductibles, co-insurance, and co-pays. These savings require enrollment in a Silver-level plan. Eligibility for CSRs applies to those with household incomes between 100% and 250% of the FPL. All Marketplace plans, regardless of metal level, must cover ten essential health benefits, including:

• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health services
• Prescription drugs

Medicaid is a joint federal and state program providing health coverage to low-income individuals and families. Eligibility is primarily based on Modified Adjusted Gross Income (MAGI) and household size. Federal law mandates coverage for certain groups, such as low-income families, qualified pregnant individuals, children, and those receiving Supplemental Security Income (SSI). Many states have expanded their Medicaid programs under the ACA to cover adults under age 65 with incomes up to 138% of the FPL. The federal government covers a substantial portion of costs for individuals newly eligible under expansion guidelines, with a 90% federal matching rate for these enrollees after 2020.

Private Market Health Insurance Solutions

Beyond government-sponsored Marketplaces, individuals can seek health insurance directly from private insurance companies. These are “off-Marketplace” plans. Direct-purchase plans are often ACA-compliant and cover essential health benefits, but they do not qualify for federal Premium Tax Credits or Cost-Sharing Reductions. Individuals pay the full premium without federal assistance.

Another private market option is short-term health plans, designed to provide temporary, limited coverage for unexpected medical events. These plans are not ACA-compliant; they are not required to cover essential health benefits, nor do they guarantee coverage for pre-existing conditions.

They often have lower premiums but high deductibles and may exclude services like maternity care, mental health, or prescription drugs. Short-term plans generally last one to four months, though some states allow longer durations. These plans are best considered a bridge during transitional periods, such as between jobs or when waiting for Open Enrollment, rather than a substitute for comprehensive health insurance.

Applying for and Enrolling in a Plan

For plans available through the Affordable Care Act Marketplace, individuals typically apply online through HealthCare.gov or their state’s marketplace. The application requires personal and financial information, including Social Security numbers, income details, and household size, to determine eligibility for plans and financial assistance. Once entered, the system displays available plans and estimated subsidies.

After reviewing plan options, individuals select a plan and enroll. The annual Open Enrollment Period for the ACA Marketplace typically runs from November 1 to January 15 in most states, with coverage starting as early as January 1 if enrolled by December 15. Outside this period, a Special Enrollment Period (SEP) may be available for individuals experiencing qualifying life events, such as losing health coverage, getting married, having a baby, or moving. SEPs usually grant a 60-day window to enroll in a new plan.

For Medicaid, applications can be submitted at any time, as there is no specific enrollment period. Individuals can apply through their state’s Medicaid agency, often online, by phone, in person, or by mail. The application requires proof of income, household size, and other identifying information. If applying through the Health Insurance Marketplace, and an individual might qualify for Medicaid, their information will be forwarded to the state Medicaid agency, which will then contact them regarding enrollment. Medicaid application processing typically involves a caseworker review and may take around 45 days, or longer if a disability determination is required.

For private market plans purchased directly from insurers, the application process involves contacting insurance companies or utilizing online comparison websites. These platforms allow individuals to research and compare plans based on their specific needs and budget. Unlike Marketplace plans, direct-purchase options do not involve a specific open enrollment period for eligibility, and applications can generally be submitted year-round. After submitting an application, individuals should expect confirmation and instructions for making their first premium payment to activate coverage.