Under-65 Healthcare

What Are My Healthcare Options If I Am Under Age 65?

For many people under age 65, healthcare coverage comes from an employer.

But what happens if you are self-employed, own a small business, retire before becoming eligible for Medicare, lose employer coverage, or simply need to purchase coverage on your own?

There may be several possibilities, depending upon your circumstances.

These can include ACA Marketplace insurance, COBRA or other continuation coverage, Medicaid or CHIP for those who qualify, employer-based options, and non-insurance healthcare arrangements such as certain health-sharing programs.

The important point is:

Healthcare coverage is not simply about the monthly payment. You need to understand what happens when you actually need medical care.

What Is ACA Marketplace Health Insurance?

The Affordable Care Act Marketplace allows eligible individuals and families to shop for private health insurance.

Marketplace plans cover the ACA’s essential health benefits, including hospitalization, emergency services, prescription drugs, laboratory services, preventive care and mental-health services. They also cover pre-existing conditions.

Depending upon household income and other eligibility factors, some consumers may qualify for a premium tax credit that reduces their monthly premium.

What Do Premium, Deductible, Copay and Coinsurance Mean?

These four words are extremely important.

Premium: What you pay to keep your health insurance in force.

Deductible: The amount you may have to pay for certain covered healthcare services before the plan begins paying its share.

Copay: A fixed amount you pay for certain covered services.

Coinsurance: A percentage of a covered medical expense that you pay.

A plan with a low monthly premium is not automatically the least expensive plan overall.

You should consider:

Monthly premium + deductible + copays + coinsurance + potential out-of-pocket exposure.

Marketplace plans also include an annual out-of-pocket maximum for covered care, which provides protection against very high covered medical expenses.

Why Does the Provider Network Matter?

Your health plan’s network is the group of doctors, hospitals and other healthcare providers that contract with the plan.

Some plans provide little or no non-emergency coverage outside their network, while others provide some out-of-network coverage at a higher cost.

Before selecting a plan, ask:

Is my doctor in the network?

Is my preferred hospital in the network?

Are my prescriptions covered?

What happens if I receive care outside the network?

HealthCare.gov specifically recommends checking provider directories and drug coverage when comparing Marketplace plans.

What Is a Health-Sharing Program?

A health-sharing program is an arrangement in which members participate in sharing eligible medical expenses according to the program’s guidelines.

Health sharing is not health insurance.

That distinction is important.

Health-sharing programs can operate differently from ACA-regulated health insurance. Eligibility, pre-existing-condition provisions, sharing limits, provider access and the types of expenses eligible for sharing depend upon the particular program.

For some individuals and families, health sharing may be an option worth evaluating. For others, traditional health insurance may be more appropriate.

The objective should be to understand both what the program provides and what it does not provide before joining.

What If I Retire Before Age 65?

Early retirement can create a healthcare gap between employer coverage and Medicare eligibility.

Possible options may include COBRA or other continuation coverage, an ACA Marketplace plan, coverage through a spouse, or another healthcare arrangement for which you qualify.

This is an important part of retirement planning because healthcare costs need to be considered before the employer paycheck and benefits stop.

What Should I Compare Before Choosing?

Don’t compare healthcare choices based only upon the monthly cost.

Consider:

What will I pay each month?

What happens if I am hospitalized?

What would I pay for surgery or expensive treatment?

Are my doctors and hospitals available to me?

How are my prescriptions handled?

Are there deductibles, copays or coinsurance?

Is there an annual out-of-pocket maximum?

Are pre-existing conditions covered or subject to limitations?

Is this health insurance, or a health-sharing arrangement?

Those questions can reveal much more than simply asking, “How much is the monthly premium?”

Start With the Total Cost of Healthcare

At Be Smart With Your Money®, we believe consumers should understand the complete healthcare picture before making a decision.

The least expensive monthly option is not necessarily the least expensive option when you actually need care.

Our role is to help you understand available healthcare choices and the important differences among them so you can make an informed decision.