Individual insurance, often referred to as “non-group” coverage, is for people who are self-employed or otherwise ineligible for insurance from other sources such as job-based group health plans, Medicare or Medicaid. Denials or restrictions in coverage, and higher premium rates due to a pre-existing condition or disability are prohibited as a result of the Affordable Care Act (ACA).
Enroll during your open (or special) enrollment period
Generally, individual insurance is ONLY available during the annual Open Enrollment period. There are exceptions for those who qualify for a Special Enrollment period. Enroll in coverage through:
- The Marketplace at www.Healthcare.gov or 800-318-2596. In some communities, information and enrollment help is available at certain hospitals, clinics, pharmacies or community service organizations. See ‘Find Local help’ at HealthCare.gov
- State exchanges in select states.
- Insurance companies that offer individual health insurance.
- An insurance agent or broker licensed by your state.
IMPORTANT: Tax credits that help make individual coverage more affordable for individuals and families are NOT available when you enroll in coverage directly through an insurance company, agent or broker. They are ONLY available through Healthcare.gov.
Watch Ask an MS Expert: Get Ready for Open Enrollment on YouTube. National MS Society MS Navigator, Nicole Vasquez, helps you navigate the open enrollment period.
Covered services, medicines and equipment
By law, most individual policies must cover 10 essential health benefits.
This includes policies sold in the Marketplace, or directly through an insurer outside of the Marketplace. All health insurance including Medicare and Medicaid plans must cover recommended preventive health services
(such as cancer screenings and vaccines) at no additional cost to you when you receive them from a provider in your plan’s network.
Prescription and provider coverage
You may have to do extra research to find out if your doctor, hospital or specific medications are covered by any of the individual plans you are considering. These and other details should be available through your state’s online Marketplace or the insurance company. This application checklist (.pdf) can help you consider an individual health plan.
Generally, people who wish to purchase or switch health insurance plans must do so during an Open Enrollment period. For coverage to begin on January 1st, make sure you enroll by December 15th.
There are exceptions for those who have a qualify for a Special Enrollment
opportunity due to certain circumstances such as moving out of state, getting married or having a baby.
Individuals or families with children but no health insurance can explore their eligibility for Medicaid or the Child Health Insurance Program (CHIP) for children under age 19 at any time. There is no open enrollment period for Medicaid or CHIP; learn about and apply for these government-sponsored health insurance programs at Healthcare.gov
Premiums vary significantly depending on location, coverage, your age and whether you use tobacco.
- Fortunately, all individual insurance plans sold through the Marketplace or state exchanges are available on an income scale. Applicants in households with income below 400% of the federal poverty level (~$98,480 for family of four in 2017) receive tax credits that are applied immediately so their monthly premiums are more affordable.
- Plans are listed as Platinum, Gold, Silver or Bronze depending on coverage. Platinum plans cover the most, bronze plans cover the least.
- ‘Extra savings’ are available for people with household income between 100% and 250% of the federal poverty level, or $30,150 to $48,240 for a household of one in 2017. You MUST enroll in a silver level plan to qualify for extra savings.
- Click here to find out if you qualify for a hardship exemption if coverage is unaffordable for you.
About the Health Insurance Marketplace
The Health Insurance Marketplace, also known as the exchange in some states, allows individuals and families to compare available health plan options, submit an application for health insurance and cost help, and enroll in their chosen health plan.
- Everything you read about your options and costs will be in plain language.
- Details about price, benefits, quality and other features are presented to help you select the plan that best meets your needs.
- Every health insurance plan in the Marketplace offers comprehensive coverage, including hospitalization, doctors’ visits, prescriptions and more.
The ACA (2010) requires tax credits that make coverage more affordable and prohibits insurers from refusing to cover or charge more if someone has a pre-existing condition, including MS. Read about the Society’s healthcare reform principles
and current advocacy issues
You can get help reviewing options and next steps
through the toll-free Marketplace help line: 800-318-2596 (TTY: 855-889-4325). If you experience difficulty accessing this toll-free service, see if there are any local help providers
in your state or community.
You must re-enroll every year.
Every fall, your health Marketplace insurance company will notify you of changes to premiums and benefits for the coming year.
- You can choose to stay in your current plan as long as it is still offered, or switch to another one that is a better fit for your needs and finances.
- You can begin comparing your options on November 1st, but you only have until December 15th to enroll in a different plan.
If you want to stay enrolled in your current plan, use the plan ID in the letter you get from your health insurer to quickly access your Marketplace account – which you will need to update or confirm your personal information.
Medicaid and CHIP enrollees must re-certify for continued coverage every year.
Each state has its own process for recertifying enrollees in these programs. Watch for notices from your Medicaid or CHIP plan and follow the procedures carefully.
Call 800-318-2596 for help re-enrolling in Marketplace, Medicaid or CHIP health coverage.