Individual Health Insurance FAQs

Do I need health insurance?

Health insurance provides you and your family affordable access to high-quality health care. Accidents and illness can happen without warning, and medical treatments can be expensive. If you do not have health insurance, you will be subject to a penalty.

What is the penalty if I don’t have health insurance?

Beginning in 2019, the penalty for not having health insurance is no longer a law.

Can my health insurance application be denied?

No. Under the Affordable Care Act, your application is approved with no pre-existing conditions or waiting periods and can no longer be denied based on your health history.

If you’re unsure if you qualify for assistance with your health insurance costs, you can get a free professional assessment from one of our knowledgeable health insurance agents or use our online quoting tool to find out if you qualify for cost savings and find a plan that works for your budget.

Is there an extra fee to use an insurance agent or broker?

No, health insurance agents and brokers are paid a commission by the health insurance company. Your insurance rates will always be the same whether you use an agent or buy directly from an insurance company. For no additional charge, an insurance agent can provide advice and assistance during the insurance application process.

What health insurance companies can I choose from?

The health insurance companies quoted by Illinois Health Agents include BlueCross BlueShield of Illinois, Coventry, Humana, Harken Health, Aetna, and United HealthOne (United Healthcare’s individual product). We will quote other insurance companies by request, but we consider these 5 companies the premier health companies in Illinois.

What is a health plan network?

A health plan network consists of all the doctors, physicians, hospitals, clinics, and specialists that agree with an insurance company to charge discounted prices for their services in exchange for patient referrals.

What is a PPO?

PPO stands for Preferred Provider Organization and is the most common type of health plan network. It consists of a managed care arrangement consisting of a group of hospitals, physicians, and other providers who have contracts with an insurer to provide health care services to enrollees at a predetermined rate.

PPOs also allow members to see physicians and hospitals out of the insurance company’s network, however, these visits will require higher out-of-pocket costs for the member. One should seek care at a PPO provider whenever possible to maximize their plan benefits.

What is an HMO?

HMO stands for Health Maintenance Organization and is a growing option for individual health plans in Illinois and nationwide. Like a PPO, an HMO is a managed care arrangement consisting of a group of hospitals, physicians, and other providers who have contracts with an insurer to provide health care services to enrollees at a predetermined rate. The biggest difference is that you are required to choose a Primary Care Physician (PCP) that accepts the plan. The PCP manages your health care needs and refers you to specialists that are within your network of coverage. This includes requiring a referral from the PCP to see a specialist.

HMOs do not allow members to see physicians and hospitals out of the insurance company’s network without a referral unless it is an emergency or an extenuating circumstance. The benefit to HMO plans is usually lower premiums and out of pocket maximums with more predictable out-of-pocket costs.

What is a Catastrophic Plan?

A Catastrophic Plan is a health plan that meets all of the requirements applicable to other Qualified Health Plans (QHPs) but don’t cover any benefits other than 3 primary care visits per year before the plan’s deductible is met. The premium amount you pay each month for health care is generally lower than for other QHPs, but the out-of-pocket costs for deductibles, copayments, and coinsurance are generally higher. To qualify for a catastrophic plan, you must be under 30 years old OR get a “hardship exemption” because the Marketplace determined that you’re unable to afford health coverage.

What is a health savings account?

A health savings account is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a High Deductible Health Plan (HDHP). The funds contributed to the account are not subject to federal income tax at the time of deposit. Funds may be used to pay for qualified medical expenses at any time without federal tax liability. Withdrawals for non-medical expenses are treated very similarly to those in an IRA account in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier. To qualify for a health savings account in 2019, one must be enrolled in a High Deductible Health Plan with a minimum deductible of $1,350 for single coverage and $2,800 deductible for family coverage.

What is a drug formulary?

This is a list of all the prescription drugs that are covered under an insurance plan.

What is a pre-existing condition?

Any health condition or illness that you had before your insurance coverage begins can be considered a pre-existing condition. Pre-existing conditions are covered on all ACA compliant plans, which includes all metal tiers and Catastrophic plans. However short term medical plans are not ACA compliant and still subject to pre-existing condition exclusions.

Will my pre-existing condition be covered?

Yes. Under the Affordable Care Act, all pre-existing conditions are covered from the first date of the policy with no waiting periods. This includes maternity coverage on all ACA plans with effective dates of January 1, 2014 and later.

Can I get individual health insurance if I smoke?

Yes. You can are eligible for the same health insurance if you smoke or are a tobacco user, but your plan can cost up to 50% more than non-smokers. Obviously, you should consider kicking the habit for your health, but also to save money. Many plans require you to be smoke-free for 12 consecutive months to get non-smoker rates.

What is the difference between individual and group health insurance?

An individual health plan provides coverage for one person, and can include children and your spouse. Group health insurance is coverage for a group of employees at a company, or members of an organization. In Illinois, a group is guaranteed health insurance, regardless of their medical conditions. However, a group’s health insurance rates are based on a combination of their demographics, type of industry the company works in, and medical history (for large groups 51+ only) are usually more expensive but often have higher levels of coverage than Individual plans.

Unlike group health plans, individual plans are available to be purchased on-exchange and off-exchange. On-exchange plans are plans that are purchase through the healthcare.gov marketplace and are eligible for government financial assistance, also referred to as subsidies. Off-exchange refers to plans that are available outside of the healthcare.gov marketplace and are not eligible for financial assistance or subsidies. Even though both marketplaces may offer plans from the same insurance company, not all of the plans are identical or “mirrored” plans. Because on-exchange plans have become more expensive and costly to insurers, off-exchange plans outside of healthcare.gov may offer plan designs with richer benefits and networks than on-exchange plans.

Healthcare.gov is a web site of the federal government that supports enrollment in only on-exchange health insurance plans. Many think it is the only place to get access to individual insurance under the ACA, but that’s just not true. You can enroll in both on and off-exchange plans through our agency or any other licensed, credentialed insurance agency to sell plans through both the private and public marketplaces.

Will my health insurance rates increase because I get older?

Yes. As people get older they tend to use more medical services, so health insurance companies accordingly adjust their premium requirements. For example, the health insurance rate charged to a 60-year-old can be up to three times more than the health insurance rate charged to a 21-year-old.

Can I add dependents to my existing individual health insurance policy?

Yes. You can automatically add newborns, but adding other dependent family members can only be added during open enrollment unless you have a qualifying event. The most common qualifying events include marriage, birth, divorce, moving (must be to a new zip code), loss of employer coverage, and adoption.

Can a health insurance company terminate my individual health insurance policy?

An insurance company can only terminate your policy if you fail to pay your premium within the allowed grace period. If you applied for your plan through the healthcare.gov marketplace and fail to submit any requested documents with 90 days, you will lose your subsidy eligibility. Your plan will not be cancelled, but you will have to pay the full amount of your plan costs without any subsidy assistance.

How do I know if I’m eligible for coverage?

In order to qualify for assistance with health insurance costs, you must:

  • Live in the United States
  • Be a U.S. Citizen or national, or otherwise legally reside in the country
  • Not be incarcerated
  • Not have access to affordable health insurance coverage through an employer, Medicare or any other source
  • Earn below 400% of the current federal poverty level

Based on the size of your household and how much you earn, you may qualify for a subsidy, also known as a tax credit. The amount of your premium tax credit is determined on a sliding scale by your earnings and the cost of coverage as a percentage of income. Specifically, the cost of coverage is based on the second cheapest silver plan on the exchange in your area. This is referred to as a benchmark plan in the ACA.

The lower your income, the higher your tax credit will be, and you may be eligible for tax credits to help pay for cost sharing if you earn up to 250% FPL. For premium tax credits, you cannot pay more than:

  • 3% of income at 133% FPL
  • 4% of income at 150% FPL
  • 6.3% of income at 200% FPL
  • 9.5% of income at 300% – 400% FPL

Tax credits can be applied to any health plan, but the value will vary based on the difference between the cost of the benchmark plan and your maximum monthly premium.

Click here to use our Subsidy Calculator