Quick Answer: Individual and family health insurance covers medical costs before you’re eligible for Medicare, through either an HMO plan (lower cost, requires referrals) or a PPO plan (more flexibility, higher cost). Many people qualify for a subsidy that lowers the monthly premium.
| Plan type | HMO or PPO, ACA Marketplace or off-exchange |
| Who it's for | Individuals and families not yet eligible for Medicare (under 65) |
| Cost help available | Premium tax credits based on household income |
| Enrollment window | Annual Open Enrollment each fall, or a qualifying life event |
| Typically covers | Doctor visits, hospitalization, prescriptions, preventive & maternity care |
| Turning 65? | Transitions to Medicare Advantage or Supplement, plus Part D |
If you’re not yet eligible for Medicare, individual and family health insurance protects you financially against the cost of unexpected illness or injury, and helps cover routine and preventive care. Choosing the right plan means understanding how you’ll access care, what it costs each month, and what you’re responsible for when you actually need to use it.
HMO Vs. PPO: How You Access Care
Most individual and family health insurance plans sold today are either HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) plans.
What Does Health Insurance Typically Cover?
Most ACA-compliant health insurance plans cover essential health benefits, including doctor visits, hospitalization, emergency care, prescription drugs, preventive care, and maternity care. Costs are typically split between a monthly premium, an annual deductible, and copays or coinsurance once you meet that deductible.
Could You Qualify For A Premium Tax Credit?
Depending on your household income, you may qualify for a subsidy that lowers your monthly premium for a Health Insurance Marketplace plan. We can help you check your eligibility and compare plans across carriers side by side, at no extra cost to you.
Turning 65 Soon?
If you’re approaching 65, your health insurance needs are about to change. We help clients transition from individual health insurance to Medicare Advantage or Medicare Supplement coverage, plus Part D prescription drug plans and hospital indemnity coverage, so there’s no gap in coverage and no surprises.
Reach out during Open Enrollment each fall, after a qualifying life event like a job change or move, or any time you’re unsure whether your current plan still makes sense.
Can I get health insurance if I have a pre-existing condition? Yes, ACA-compliant plans can’t deny coverage or charge more based on pre-existing conditions.
What’s the penalty for not having health insurance? There’s no federal tax penalty currently, though some states have their own requirements.
How do I know if I qualify for a subsidy? Eligibility is based on household income and size; we can check this for you at no cost.
Contact us to schedule a no-obligation appointment to go over the health insurance plans available to you and find one that fits your needs and budget.
HMO plans require a primary care doctor and referrals to see specialists, using in-network providers only, usually for a lower premium. PPO plans let you see specialists and out-of-network providers without a referral, usually for a higher premium.
Most individual health insurance follows an Annual Open Enrollment Period each fall for coverage starting January 1. Outside that window, you generally need a qualifying life event — like losing other coverage, moving, marriage, or having a baby — to enroll.
Many people qualify for a premium tax credit based on household income and family size, which lowers your monthly premium for a Marketplace plan. We can check your eligibility at no cost.
You’ll generally transition from individual health insurance to Medicare. We help clients plan that switch in advance so there’s no coverage gap and no late enrollment penalties.