Read on for tips and information that can help when shopping for health insurance if you’re self-employed or unemployed – including for retirees too young for Medicare.
Where to shop for health insurance
You can shop for health plans on the Affordable Care Act (ACA) Health Insurance Marketplace at HealthCare.gov or directly through an insurer like Cigna Healthcare. The ACA Marketplace is operated by the federal government, though some state governments opt to run their own exchanges.
When to shop for health insurance
The Open Enrollment Period is the time when individuals and families can buy a new health plan or make changes to their current health plan on the ACA Marketplace. Open Enrollment begins on November 1 each year and has a December 15 deadline for purchasing plans that take effect January 1, and a January 15 deadline for plans that go into effect on February 1.
Special Enrollment Periods are available to get coverage or change plans at other times of year. To qualify, you must have experienced a life change within the last 60 days such as losing your health coverage from an employer or program like Medicaid, getting married, or having a baby. Additionally, individuals whose income falls at or below 150% of the Federal Poverty Line (FPL), which is approximately $19,000 for an individual and $40,000 for a family of four, may be able to enroll or change their plans throughout the year.
What to look for when shopping for health insurance
When you shop for an individual or family plan, the first thing you’ll want to look at is the premium, which is the price you will pay for your health plan – typically on a monthly or twice-per-month basis. Think of it like a subscription fee you’d pay for a streaming service. You pay for your insurance to have that protection in place, even if you don’t go to the doctor that month, just as you’d pay for streaming even when you’re not watching a show.
When you buy insurance through the ACA marketplace, premiums vary by which benefits you choose, your age, where you live, and by insurance carrier.
Depending on your income, you may be able to qualify for subsidies, including tax credits that can lower your monthly healthcare expenses by adjusting your premium. Due to changes made throughout the pandemic, and extended through 2025 through the Inflation Reduction Act, more people than ever quality for subsidies on the marketplace, so be sure to check if you qualify. Many people qualify for subsidies that reduce their premiums to $0 per month.
Premiums are a starting point for determining which health plan is the best fit for your budget and needs, but it’s not the whole picture. Factors like deductibles, network coverage, co-pays, out-of-pocket limits, and your unique healthcare needs also should be considered to determine the overall affordability of a plan.
Key healthcare terminology to help you shop for a plan
To make an informed decision when shopping for a health plan, it’s important to understand some key terminology and factors which can significantly impact overall costs. Most terms that come up during open enrollment are plan features that can factor into the overall amount you pay for healthcare.
Deductible: Your deductible is the amount of money you need to pay for medical care before your health plan starts sharing costs. For example, if your deductible is $1,500 for the year, you will pay out of pocket for all care (except for preventive care, such as annual check-ups) until you’ve spent $1,500.
Choose a health plan that has a deductible you can afford, since this comes from your own pocket if you have healthcare expenses. Also, be sure to check to see whether a plan you’re considering has a separate deductible for healthcare services and for pharmacy – you’d be responsible for each.
Network: A network is a group of medical care providers, such as doctors, pharmacies, and specialists, that are contracted to serve customers of certain health plans. You’ll want to make sure your and your family’s preferred doctors and pharmacies belong to the network of the plan you’re choosing. Otherwise, you’ll rack up unwanted costs for out-of-network services.
Copay: A copay is a flat fee that you pay when you visit the doctor or get a prescription from the pharmacy. When plans include copays, they cover your portion of the cost of a doctor's visit or medication. If you select a health plan with copays, the amounts will be listed on your health plan ID card.
Coinsurance: Instead of copays, plans can include coinsurance – you pay a percentage of the costs for covered services, and your health plan pays the rest. Depending on your plan, your coinsurance usually kicks in after you meet your deductible.
Out-of-pocket maximum: The out-of-pocket maximum is the most you could pay for covered medical expenses in a year. This amount includes money you spend on deductibles and copays or coinsurance. If you reach your annual out-of-pocket maximum, your health plan will pay all covered costs for the rest of the year.
Navigating Different Types of Health Plans
Networks and costs can differ widely between the three types of health plans: health maintenance organizations (HMOs), preferred provider organizations (PPOs), and exclusive provider organizations (EPOs).
An HMO health plan gives you a local network of doctors, hospitals, and other healthcare professionals and facilities to choose from. These types of health insurance plans require you to select a primary care provider (PCP) from within the network. Your PCP is at the center of your medical care, getting to know you, helping coordinate all your care, and providing referrals to see in-network specialists. The costs for an HMO plan – copays and coinsurance – are typically lower than for other types of health plans, as long as you stay in network.
A PPO health plan offers a larger network, so you have more doctors, hospitals, and other healthcare facilities to choose from. Your out-of-pocket costs are usually higher with a PPO than with an HMO or EPO plan. If you're willing to pay a higher monthly premium to get more flexibility in choosing your physician and healthcare options, a PPO health plan might be a fit for you.
An EPO health plan offers a local network of doctors and hospitals for you to choose from. An EPO usually has lower out-of-pocket costs than a PPO plan. However, if you choose to get care outside of your plan’s network, it may not be covered (except in an emergency). If you’re looking for lower monthly premiums and are willing to pay a higher deductible when you get care, an EPO plan might be right for you.
Health plans for younger individuals
If you’re in good health and don’t visit a doctor often, health plans with higher deductibles typically have lower insurance premiums and could help save you money. All plans available through the ACA Marketplace cover basic preventive services at no cost. This includes an annual physical, recommended screening tests, and vaccines.
Your healthcare needs are unique, and they will change over time. Rather than just considering your age when you pick a plan, think about what you might need in the coming year.
Health plans for families with children
If you have children, chances are it’s harder to estimate your healthcare expenses. A fall on the playground, a bout of respiratory syncytial virus (RSV) or the flu, or other illnesses or injuries can quickly drive up costs. A plan with a lower deductible and higher premium that pays for a greater percentage of your medical costs may be better for your family.
Take the time to understand a plan’s mental health coverage
To better understand the mental health coverage of a health insurance plan, you’ll usually need to look at the Summary of Benefits. This is a document that shows what services the plan covers and what you pay for covered services. Typically there will be a line describing coverage for mental health, behavioral health, or substance abuse services. Depending on your mental healthcare needs, this may be one of the deciding factors in how you choose your plan.
It can be useful to look at plan brochures to see if there are any additional plan features that impact access to mental healthcare. For example, Cigna Healthcare individual medical plans offer additional access to virtual behavioral health services through MDLIVE – a leading virtual and telehealth care provider with more than 2,500 board-certified doctors and behavioral care providers.
Even if you haven’t been diagnosed with a mental health condition, a plan with behavioral health coverage can ensure you get specialized care should you need it. An Evernorth study published in the Journal of the American Medical Association suggests that when needed, outpatient behavioral care can significantly reduce your total healthcare costs – including your medical and pharmacy costs.
How To Research Your Plan Options
To view which plans are available in your area, visit HealthCare.gov and enter your ZIP code or visit Cigna Healthcare's website. If you have specific questions about certain plans or providers, most insurers have customer service advocates who can answer questions about their respective plans. For more comprehensive guidance, you can get local help through HealthCare.gov/find-assistance from a broker who specializes in ACA plans to help determine what might be best for you, or an assistor who can walk you through your options and specific needs.
Cigna Healthcare Insurance Plans for Individuals and Families
Open Enrollment for Cigna Healthcare Individual and Family plans runs from Nov. 1-Jan. 15, 2023. During this time, you can check if you qualify for financial help, compare plans, and apply.