How Much Is Health Insurance in NC for One Person?

Health insurance costs for individuals in North Carolina vary based on personal circumstances and coverage type. Understanding these factors and available options helps in making informed decisions to find a plan that aligns with health needs and financial considerations.

Factors Influencing Health Insurance Costs

Monthly premiums for individual health insurance in North Carolina are directly affected by several variables. Age plays a role, with premiums increasing as an individual gets older due to higher anticipated healthcare utilization. Geographic location within North Carolina also impacts costs, as insurers divide the state into rating areas where healthcare expenses vary. Another factor is tobacco use, which can lead to higher premiums for individuals who use tobacco products.

Beyond personal characteristics, the health plan’s structure heavily influences its cost. Plans available through the Affordable Care Act (ACA) Marketplace are categorized into “metal tiers”: Bronze, Silver, Gold, and Platinum. These tiers reflect the plan’s actuarial value, indicating the average percentage of healthcare costs covered for a standard population. For instance, a Bronze plan covers approximately 60% of healthcare costs, while a Platinum plan covers around 90%.

The choice of metal tier represents a trade-off between monthly premiums and out-of-pocket costs. Bronze plans have the lowest monthly premiums but come with higher deductibles, copayments, and coinsurance, meaning individuals pay more when they receive care. Conversely, Platinum plans feature the highest monthly premiums but offer the lowest out-of-pocket costs and deductibles. Silver plans are a benchmark, providing moderate premiums and moderate out-of-pocket expenses, often with deductibles lower than Bronze plans.

Out-of-pocket costs are important for understanding a health plan’s total financial impact. A deductible is the amount an individual must pay for covered services before the insurance company begins to pay, except for preventive care covered at no cost. Once the deductible is met, copayments (fixed amounts for specific services like doctor visits) and coinsurance (a percentage of the cost for a service) may apply. All plans have an out-of-pocket maximum, which is the most an individual will pay for covered services in a plan year; once this limit is reached, the plan pays 100% of additional covered costs.

Available Coverage Options

Individuals in North Carolina have several avenues for obtaining health insurance coverage, each with distinct characteristics and eligibility.

Affordable Care Act (ACA) Marketplace: A primary source for individual coverage is the Affordable Care Act (ACA) Marketplace, which operates as a federally-facilitated exchange through Healthcare.gov in North Carolina. This platform offers plans from various private insurers, with nine providing options for 2025. ACA-compliant plans cover essential health benefits and cannot deny coverage based on pre-existing conditions.

Medicaid: Medicaid offers free or low-cost health coverage for those with lower incomes. North Carolina expanded its Medicaid program as of December 1, 2023, making adults with incomes up to 138% of the Federal Poverty Level (FPL) eligible. For children, the state offers NC Health Choice, North Carolina’s Children’s Health Insurance Program (CHIP), providing comprehensive benefits for uninsured children up to age 19 in families with incomes up to 200% of the FPL. Eligibility depends on income, family size, and residency.

Medicare: Medicare is a federal health insurance program primarily for individuals aged 65 or older. Younger individuals may qualify if they have certain disabilities or End-Stage Renal Disease (ESRD). Medicare has different parts, including Part A (Hospital Insurance) and Part B (Medical Insurance). Most people do not pay a premium for Part A if they or their spouse paid Medicare taxes for at least 10 years.

Short-Term Health Plans: Short-term health plans are another option, though they differ significantly from ACA-compliant plans. These plans are intended to cover temporary gaps in coverage, such as between jobs or while waiting for other insurance to begin. They do not cover pre-existing conditions and do not provide the comprehensive essential health benefits mandated by the ACA, such as maternity care, mental health services, or prescription drugs. Short-term plans have lower monthly premiums but carry higher financial risks due to limited benefits and potential for retroactive cancellation if medical conditions are undisclosed.

Understanding Financial Assistance

To make health insurance more affordable, financial assistance is available, primarily through the Affordable Care Act (ACA) Marketplace. The two main forms of assistance are Premium Tax Credits and Cost-Sharing Reductions, which lower the financial burden for eligible individuals and families by reducing both monthly premiums and out-of-pocket costs.

Premium Tax Credits, or subsidies, directly reduce the amount an individual pays each month for their health insurance premium. Eligibility for these tax credits is determined by household income relative to the Federal Poverty Level (FPL). For instance, in early 2024, approximately 96% of Marketplace enrollees in North Carolina received premium tax credits, which averaged $558 per month, resulting in an average monthly cost of about $70 after subsidies.

Cost-Sharing Reductions (CSRs) lower the out-of-pocket costs associated with a health plan, such as deductibles, copayments, and coinsurance. Unlike Premium Tax Credits, CSRs are only available for Silver-level plans purchased through the Marketplace. Individuals must have incomes below a specific FPL threshold to qualify for CSRs, which increases the actuarial value of a Silver plan beyond the standard 70%, meaning the plan covers a higher percentage of medical expenses. For example, a Silver plan with CSRs might cover 73% to 96% of costs, depending on the income level.

The income thresholds for eligibility are updated annually and are tied to the Federal Poverty Level guidelines. While Premium Tax Credits reduce the monthly premium, Cost-Sharing Reductions directly lessen the amount an individual pays when they use healthcare services.

Steps for Finding a Health Plan

Finding a health plan in North Carolina, particularly through the Affordable Care Act Marketplace, involves a structured process to compare options and enroll. The primary platform for individuals to explore and purchase ACA plans is Healthcare.gov.

To begin, an individual creates an account on Healthcare.gov and provides basic personal information, including household size and estimated income. This information determines eligibility for financial assistance, such as Premium Tax Credits and Cost-Sharing Reductions. The system then displays available plans and their adjusted costs based on the provided details. It is important to accurately report income and household changes to ensure correct subsidy amounts.

When comparing plans, individuals can filter options by criteria including monthly premium, deductible amount, and out-of-pocket maximum. Consider the total estimated annual costs, not just the monthly premium, by factoring in potential deductibles and copayments based on anticipated healthcare needs. The Marketplace allows for comparison of different plan network types, such as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), and Point of Service (POS) plans. These dictate how individuals access care and whether referrals are needed.

Enrollment in Marketplace plans occurs during the annual Open Enrollment Period, which runs from November 1 to January 15. For coverage to begin on January 1, enrollment must be completed by December 15. Outside of this period, individuals may qualify for a Special Enrollment Period (SEP) if they experience a qualifying life event. These events include:
Losing existing health coverage
Getting married
Having a baby
Adopting a child
Permanently moving to a new area

If a qualifying event occurs, individuals have 60 days to enroll in a new plan.