Individual Medical Insurance Plans – Are You Covered?


Americans spend more on healthcare than any other country in the developed world. Figures recently gathered put the annual spending for 2018 at $3.65 trillion. This figure is an increase on the previous year, and it seems that spending isn’t slowing down. Divide this staggering figure up into personal expenditures, and that’s more than $11,000 per person. More than 50% of the money spent goes to hospitals, clinical services, and doctors. 

To help cover the cost of increasing prices, more and more people are choosing to purchase medical insurance plans for individuals. With an average cost of $440 for individual health plans and $1,168 for a family, personal medical insurance certainly looks like a worthwhile option. 

Have you been thinking about your health insurance? Would you like to know the best providers to choose from? Are you looking for an alternative to group health insurance? If you’d like to know more about medical insurance plans for individuals, this guide is going to provide the answers. With this information, you’ll be able to take advantage of special enrollment periods.

Medical Insurance Plans for Individuals – What Are They?

Medical insurance plans, also known as health insurance plans, are a type of insurance. Coverage includes the cost of the insured person’s medical and surgical expenses. The medical expenses can be incurred at any number of different providers, for example, a clinic, hospital, doctor, healthcare practitioner, laboratory, or pharmacy. 

There are two ways the expenses can be covered. The first is when the insurer makes payments directly to the provider. The second option is when the insured person pays the bill and requests reimbursement.

In the US, people have two health insurance options. For those unemployed or self-employed, you can purchase a personal medical insurance plan. If, on the other hand, you’re working, health insurance generally takes the form of an employer’s plan, which forms part of your benefits package.

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Different Types of Health Insurance Plans

There are two different types of health insurance available: 

Private Health Insurance

In 2018, a survey was conducted that found 65.1% of people interviewed under the age of 65 had private medical insurance. Private health insurance provided by insurance companies is paid for through a premium charged to the individual, the employer, or a combination of both.  

According to the Centers for Disease Control and Prevention, private health care is relied upon heavily by the US healthcare system. 

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Government or Public Health Insurance

Organizations such as Medicare, Medicaid, the Indian Health Service, and the Veteran’s Health Administration offer health insurance coverage subsidized by the government or other funding organizations rather than charging an individual premium.

There are also different types of plans within these two categories.

Managed Care Plans

Low-cost medical care is provided for policyholders because the insurer has contracts with a network of healthcare providers. Insured people should aim to use these providers whenever possible. Out-of-network care is available, but it often comes with additional costs or a penalty payment. 

The cost of a managed care plan varies considerably. As a general rule of thumb, you can expect to pay more for a more flexible policy.   

Fee-For-Service, or Indemnity Plans

With this type of insurance plan, treatment is covered equally, whatever healthcare provider you use. The benefit of this is you can choose where you receive treatment.

 With an indemnity plan, the insurer pays 80% of the cost, sometimes a little bit more. The remaining cost has to be paid by the insured person. This is known as co-insurance.  

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HMOs or Health Maintenance Organizations

Organizations that provide medical care directly to the insured are known as HMOs. It’s usual for this type of policy to mention a primary care physician specifically. This physician is responsible for the required care and is usually a general practitioner (GP) who is the first treatment provider for the individual. For the cost of treatment to be covered, it has to be referred by the specified physician or GP. Because the GP has previously negotiated fees for various services, the cost of treatment is usually lower. An HMO plan is also one of the best low-cost health insurance plans available. 

PPOs or Preferred Provider Organizations

PPO plans are very similar to a fee-for-service or indemnity plan. Insured people can visit any doctor they prefer. The difference is that there is also a network of approved providers with whom the PPO has negotiated costs. The PPO thus offers more flexibility of treatment options plus the benefit of saving money within the provided network.  

Point of Service Plans

These are a combination of an HMO and PPO plan. An insured person is recommended for treatment by a primary care physician to a provider that may be within the insurer’s network or from somewhere outside of the network. If the patient chooses to go outside the network, then less of the treatment is covered, and the patient is responsible for filing all necessary paperwork.

Catastrophic Health Insurance Plan

There’s one final type of health insurance worth mentioning, and that’s catastrophic plans. These health plans are perfect for those on a tight budget. Monthly premiums are low, but you pay a high deductible. 

Do you know what a deductible is? It’s the percentage of the cost of your treatment that you pay for yourself. For example, if a policy states the deductible is $1,500, you pay the first $1,500 of covered services out of pocket. A high-deductible health plan generally comes with a low monthly premium.    

Individual Medical Insurance Plans

What Type of Treatment Does an Individual Medical Insurance Plan Cover?

Whether you have individual insurance or are part of an employer-sponsored health insurance plan, you’ll find coverage for a variety of different treatments. When comparing policies, always check the services included. While there may be individual differences, most cover essential health benefits and preventive care services. These are a requirement as part of the Affordable Care Act. This act also establishes open enrollment dates every year. The essential benefits include:

  • Care you receive as an outpatient, without being admitted to a hospital
  • Emergency services
  • Hospitalization
  • Maternity and newborn care 
  • Substance abuse and mental health services
  • Rehabilitative and habilitative services
  • Prescriptions
  • Laboratory services
  • Pediatric services
  • Preventive and wellness services
  • Chronic disease management

What to do When Services Aren’t Covered

If your doctor decides you require some kind of treatment as a necessity for your health, your insurance may not cover it. Your doctor may not know what treatments are included, but you can help by reading and understanding your insurance policy. Medical policies include a list of excluded services that are essential to be aware of as you make healthcare choices. If you have any questions about upcoming treatment, call your insurance company and ask whether it’s covered. 

When your health insurance doesn’t cover a specific treatment, you can still choose to receive it. You will, however, have to pay for the treatment, out-of-pocket. There is the option of filing a claim if your insurance company doesn’t consider the treatment under its coverage. For this, you’ll have to follow the insurance company’s appeal process. The details are in your plan handbook.

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The Benefits of Individual Medical Insurance Plans

The most obvious benefit of private health insurance is that it provides coverage for many of your regular healthcare expenses. Most types of insurance cover the cost, either in part or in full, of visits to your doctor, emergency visits, and some specialist treatments. Depending on your particular policy, large hospital bills connected with surgery or some other kind of major treatment may also be covered. 

Choose a PPO plan, and you’re able to choose your doctor, although there may be costs to pay if they’re not part of your provider’s network. 

When compared with public insurance plans, such as Medicare or the Children’s Health Insurance Program (CHIP), you get more choice. Ultimately, this means you’re able to pick a plan that suits your needs. 

Extra benefits that come with an individual medical insurance plan include shorter waiting times, personalized attention, and access to the latest facilities. 

Are there any downsides to choosing individual medical insurance? As with most things, yes there are. The first has to be the cost. Not everyone can afford to pay extra for their healthcare, and some policies can cost several hundred dollars every month. Coverage for a family can cost even more. Another downside is that health insurance doesn’t cover all conditions and diseases. If the policy doesn’t include the condition you’re suffering, the cost of your treatment falls on your shoulders.

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What is the Average Cost of Personal Health Insurance?

How much you pay for your health insurance is a complicated figure to quantify. It all depends on your age and where you live. If you’re young and healthy, you can expect to pay less than someone older. Your location also makes a big difference to the cost. In Alaska, for example, the average annual health insurance cost for a person aged 21 is $5,112. In Alabama, on the other hand, it’s only $2,604. 

Health insurance plans are separated into tiers, and these can also have a bearing on premiums. The tiers are catastrophic, bronze, silver, gold, and platinum. Costs range, on average, from $167 per month for catastrophic to $363 per month for premium. This classification relates to the costs the insurance plan covers.  

To complicate the subject of cost even further, the type of plan you choose can also change the rate you pay. The cheapest kind is generally an HMO. This is because it’s the most restrictive as far as the doctors you can see. Other plans are more expensive because you’re able to access a wider variety of healthcare providers.

Other Factors That Impact of Your Insurance Costs

Age, location, tier, and type of insurance all impact the cost of coverage; however, there are two more factors to bear in mind. Do you smoke or use tobacco? If you do, don’t be surprised to find yourself paying an extra 50% in monthly premiums. The number of people covered under your insurance is the final factor to consider. Their ages and whether they smoke are also going to affect the total cost of your plan. 

Once you have a grasp of the basic types and costs of health plans, it’s time to look at some of the top individual medical insurance plans.

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Top Insurers in the Health Insurance Marketplace    

Every person’s needs are different, which makes it very difficult to provide you with a one-size-fits-all list. It is possible, however, to provide you with a list of the five best plans available. 

Blue Cross Blue Shield

Blue Cross Blue Shield is a long-standing provider that offers a wide range of plan options, so you should have no problem finding a plan to meet your needs. Coverage is broad, but it does depend on where you live. There are 20 plans to choose from. Compared with other providers, costs are average. 

Benefits are available through the health and wellness program, and there are discounts for diets, health clubs, fitness monitors, and a range of other health-related products. You also get access to a prescription manager through whom you order medicine via mail or online. Another handy feature is that you can find in-network doctors through the Blue Cross website or by using the app.  


Humana is the best provider for people over the age of 45. However, it’s only available in 22 states. Premiums are lower across the board, but particularly for seniors. There are only a dozen or so plans to choose from, but this should be more than adequate for most people’s needs. An attractive addition for the older population is home healthcare coverage. Long-term care insurance is an excellent supplement for people with chronic illness who want to continue living in their own homes.

Additional features include access to wellness benefits such as HumanaVitality and an online rewards program aimed at those who want to develop healthy habits.  

One downside is that Humana doesn’t offer short-term health plans. This means it’s not the right provider if you’re in-between jobs or are waiting for your new employer-sponsored health insurance to kick in. 

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Medical Mutual

Medical Mutual is a Medicare insurance provider and is one of the largest and oldest health insurance companies in Ohio. Unfortunately, it only covers Ohio, but, if you’re lucky enough to live there, this provider is worth considering. There are more than 43,000 primary care and specialist providers in the network, including providers in every county. Nearly all (99%) hospitals in the state are also part of the network. That means there’s at least one hospital in every metro area.

For more information, visit the Medical Mutual website.


UnitedHealthcare is the largest provider of health insurance in the US. The individual medical insurance plans it provides meet the Affordable Care Act requirements for essential care. One of the most significant benefits of this provider is access to online care. This feature includes ordering prescriptions online and getting online advice using the “nurse to help” hotline. It’s also possible to go online at any time of the night or day and set up doctor’s appointments, file claims, and find a doctor. If you’re out and about, you can do all this using the UnitedHealthCare mobile app. Short-term health insurance is also available.  

Discounts are offered for vision services and hearing aids, as well as for stopping smoking programs. The network of participating physicians is a staggering 790,000. 

One downside is that UnitedHealthCare is one of the more expensive providers, with premiums as much as $600 per month. You can work out the actual cost of your premium online by visiting the company website.    

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HCSC stands for the Health Care Service Corporation and is one of the largest customer-owned US health insurance providers. Across the states of Illinois, Montana, New Mexico, Oklahoma, and Texas, there are more than 15 million members. Coverage options and plans vary depending on the state, so it’s difficult to provide too many details. For relevant information, you should visit the HCSC website.

There are, however, benefits that apply across the board, including fitness programs, maternity programs, stopping-smoking support, weight-loss programs, and an online health assessment tool. A 24/7 nurse hotline is also available. 

If you want to reduce your health insurance premiums, a high deductible plan is an option. 

Individual Medical Insurance Plans

How to Find Health Insurance

We’ve given you five suggestions of providers you can use. However, if these don’t suit your needs, there are other ways to find the best provider.

The internet is an excellent tool to use when looking for insurance. Type in “individual medical insurance plans,” and you’ll get millions of hits. It’s then a case of sifting through all the providers and finding one that meets your needs.

Another option is to use your state’s Affordable Care Act marketplace, federal marketplace, or a health insurance marketplace. The best place to start your search is by going to healthcare gov. Enter your ZIP code, and you’ll get the necessary details.

Private exchanges are another option; however, bear in mind that you won’t be eligible for premium subsidies.

How to Keep Your Healthcare Cost Low

The cost of healthcare has been rising steadily over many years, and there appears to be no let-up. While health insurance can help with the price, there are also ways you can reduce your out-of-pocket healthcare costs. Learning how to save money while still receiving the care you need is essential. The following tips will help you save cash.  

Invest in the Best Health Insurance

Cheap health insurance is a temptation, and, at first, it might look like you’ll be able to keep costs low. It can, however, cost in other ways. Certain things might not be covered, and your deductibles are likely to be higher, as might be the copay. You should, however, choose the affordable health insurance plan that covers your needs. It also pays to take advantage of open enrollment periods because these are an opportunity to change providers. Open enrollment is available once every year.  

Understand Your Health Benefits

Review your plan’s policies today and see what they cover and what costs you’ve got to pay. If there are any aspects of your coverage you don’t understand, call your provider and ask all the questions you need.  

Use Generic Rather Than Brand Name Drugs When Possible

Brand-name medications can be costly. When receiving treatment, ask your doctor if there’s a generic alternative you can use. Generic drugs work the same, and you could be saving in copays.  

Buy Your Medication in Bulk

if you take prescription drugs or other medicines regularly, it might pay to buy in more significant amounts. Ninety-day supplies, for example, save money in many ways. For instance, you won’t need to travel to the pharmacy so often.

Take Advantage of Free Medication Samples

Doctors often receive free samples from pharmaceutical reps. Ask your provider whether there are samples available as a way of saving money. 

Look Into Patient Assistance Programs

Drug companies and nonprofit organizations run patient assistance programs. They might also be state-sponsored. If you can demonstrate the financial need for assistance, you might qualify. Approval means you’ll lower costs instantly, but still be able to access the drugs you need.

Review Your Medical Bills

Mistakes can happen, so it pays to review your medical bills regularly. It’ll be much easier to change the bill if something is wrong than to try to claim money back at a later date. 

Negotiate Services

If your insurance provider refuses to pay for particular treatments, don’t be afraid to enter into negotiations with your medical provider. They might be able to help with your out-of-pocket expenses. Reduced rates might also be available for those without coverage.   

Appeal Denied Claims

You can also appeal denied claims with your insurance provider. The process you have to go through will vary depending on your provider. However, all it usually requires is filling out some forms and requesting that your provider reconsider the decision.

Avoid the ER if Possible

There are times when a trip to the ER is essential. However, unless you need to go to the hospital, it’s a good idea to avoid costly ER visits. Walk-in clinics are usually cheaper, and you probably won’t have to wait so long. 

Consider an FSA or HSA

If your employer offers an HSA or FSA, consider opening one. These are savings accounts that give you the option of setting aside pre-tax money to cover health care expenses. It’s a way of saving several hundred dollars every year. If you open an HSA (Health Savings Account), you own the account. This means you earn interest, and it is transferred if you change your employer. FSAs (Flexible Spending Account), on the other hand, are owned by an employer. They don’t earn any interest, and you must use the money set aside within a calendar year.  

Look Into Claiming Subsidies

Government help is available to help people pay their health insurance costs. Subsidies are available under the Affordable Care Act. 

If you’re looking into purchasing individual health insurance, we’d love to hear about your experience. If there’s some information we’ve missed or something that you think it is worth sharing, leave a comment below. In the interest of providing the best information for our readers, we appreciate any real-life experiences you’ve got to share.


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