Assisting Oregonians since 2006
Individuals and Families Health Plans
A Comprehensive Guide
Individuals and Families Health Plans (IFHP) are essential for ensuring access to quality health care for individuals and families. These plans offer a range of benefits, including coverage for preventive care, doctor visits, hospitalization, and prescription drugs. With so many options available, choosing the right health plan can be a complex and confusing process.
Health Plans In Oregon has helped individuals and families find affordable health insurance plans based on their unique needs and budgets since 2006. We also help you apply for financial assistance you may qualify for through the Health Insurance Marketplace to help reduce your monthly health insurance costs.
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Individuals and Families Health Plans are health insurance policies designed specifically for individuals and families who do not have access to employer-sponsored health insurance.
They offer comprehensive health coverage, including preventive care, doctor visits, hospitalization, and prescription drugs, among other benefits.
These plans can be purchased directly from an insurance company or through the health insurance marketplace.
Benefits of Individuals and Families Health Plans
Individuals and Families Health Plans offer several benefits, including:
- Affordable coverage: IFHP provide a cost-effective way for individuals and families to access quality health care without having to pay for expensive medical bills out of pocket.
- Comprehensive coverage: IFHP typically offer a wide range of benefits, including preventive care, doctor visits, hospitalization, and prescription drugs, among other services.
- Access to quality care: By providing access to quality health care, IFHP help individuals and families maintain good health and prevent the onset of serious medical conditions.
- Peace of mind: With IFHP, individuals and families can rest assured that they will have access to medical care when they need it, without having to worry about the financial burden of medical bills.
Coverage Options in Individuals and Families Health Plans
If you are a member of a federally-recognized Native American and/or Alaska Natives tribe, you can qualify for special benefits, including a zero-cost sharing plan, when you enroll for a private health insurance through the insurance marketplace. Eligibility requirements depend on income at or below the limit for your family size, such as $75,300 for a family of four.
If you work for a small business, check to see if your employer offers group insurance. It is normally offered to full-time employees and the employer can choose to cover at least 50% of the employees premium.
The Health Insurance Marketplace offers private health plans and financial help for people who earn too much to qualify for the Oregon Health Plan and/or cannot get health coverage elsewhere. All plans in the insurance marketplace include comprehensive health benefits meeting state and federal requirements and many receive tax credits that pay below the full price of their health plan cost.
The Oregon Health Plan is a free health insurance plan for Oregonians who meet income, age, and other immigration and residency requirements. OHP covers medical care like doctor visits, hospital services, mental health care, dental, and some vision care. Oregon became the 7th state in the country to provide free healthcare for kids through the Cover all Kids initiative. It extends healthcare coverage through the OHP for all children up to 300% of federal poverty level.
The Premium Assistance Program for COFA provides free health insurance for low-income citizens who live in Oregon from the Republic of the Marshall Islands, the Federated State of Micronesia, and the Republic of Palau. Eligibility requirements include adults at least 19 years-old, not pregnant, residing in Oregon, earning below the income criteria, and who are not eligible for coverage elsewhere.
A recent survey suggests 95% of Oregonians have health insurance (about 3.7 million out of 4.1 million people in Oregon). Despite these stable levels of insurance coverage, managing sustainable coverage rates is always a battle.
Health Insurance Rates increase relatively modest every year, but individuals and families should still review all available policies and pick a health insurance plan that is best suited for their needs and budget.
Choosing the Right Individuals and Families Health Plan
Choosing the right Individuals and Families Health Plan can be a complex and confusing process. Here are some factors to consider when selecting a plan:
- Coverage: Consider the coverage options offered by the plan, including preventive care, doctor visits, hospitalization, and prescription drugs. Make sure the plan covers the services you need and those you are likely to need in the future.
- Cost: Consider the cost of the plan, including the monthly premium, deductibles, copayments, and coinsurance. Make sure you can afford the plan and that it fits within your budget.
- Network: Consider the network of providers covered by the plan. Make sure the plan covers the doctors and hospitals you prefer, and that you have access to quality care.
- Benefits: Consider the benefits offered by the plan, including wellness programs, health savings accounts, and other value-added services.
What Does Individuals and Families Health Plans Cover?
Individuals and Families Health Plans typically cover a wide range of medical expenses, including:
- Doctor visits
- Hospital stays
- Prescription drugs
- Emergency room visits
- Lab tests and X-rays
- Preventive care
- Mental health services
- Substance abuse treatment
- Maternity and newborn care
How Much Does Individuals and Families Health Plans Cost?
The cost of Individuals and Families Health Plans varies depending on several factors, including:
- Family size
- Level of coverage
- Smoking status
- Pre-existing medical conditions
Individuals and Families Health Plans Enrollment Period
- The Annual Open Enrollment for individuals and families health insurance begins November 1 and end December 15 for an effective date of January next year
- Individuals and families with a qualifying life event (QLE) are eligible for a special enrollment period (SEP) and can enroll within 60 days of lapsed coverage (See below for more information)
- Employers re-enroll on their anniversary dates
- Small businesses can enroll anytime
Good news: You may still qualify for Special Enrollment Period (SEP).
If you answer “Yes” to any of the answers below, you are still able to enroll in a plan within 60 days after a qualifying life event.
- Did you get married?
- Have you had a baby, adopted a child, or placed a child for foster care?
- Have you got divorced or legally separated and lost health insurance?
- Did you move and change residence?
- Did you or anyone in your household lose qualifying health coverage in the past 60 days?
- Did you leave incarceration?
- Did you just become a U.S. citizen?
According to healthcare.gov, these health care benefits should all be covered:
- Ambulatory patient services (outpatient received without admittance to a hospital)
- Emergency services
- Hospitalization (like surgery and overnight stays)
- Pregnancy, maternity, and newborn care (both pre and postnatal)
- Mental health and substance abuse disorder services, including behavioral health treatment (counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (helping people with injuries, disabilities, chronic conditions, or recovering mental and physical skills)
- Laboratory services
- Preventive and wellness services
- Chronic disease management
- Pediatric services, including dental and vision care
The best part of individuals and families health insurance is that health plans must cover treatment for pre-existing medical conditions. No credible health insurance carriers can decline or ask you to pay more for your needed health coverage just because of a medical condition you had before your plan started.
One of the biggest concerns in the healthcare industry is finding insurance that covers preexisting condition. Thankfully, the ACA made it possible for millions of Americans to no longer be denied health insurance because of complex qualifications or preexisting conditions when it went into effect in January of 2014.
Insurance companies are now prohibited from charging higher premiums, limiting benefits, or denying coverage to those who need it. The ACA even created a Pre-existing Condition Insurance Plan (PCIP) which takes care of primary and specialty care services and prescription drugs. More than 50,000 Americans have since enrolled in PCIP.
Individuals and Families Health Plans Metal Tiers
Types of Individuals and Families Health Plans
HMO plans offer health care services through a network of providers who agree to lower rates or provide services only to its members. With this health plan, you have a primary care doctor who must be in your HMO network. If you need a specialists, they must refer you. If you see a doctor outside of this network, you will have to pay the full amount. Kaiser Permanente is a well-known example of an HMO plan in Oregon.
PPO plans allow you to see any in-network health care provider without a referral from your primary care physician. You may see out-of-network providers but you will pay a higher amount. PacificSource is one of the PPO plan options in the Oregon market.
Like PPO, EPO plans let you see health care providers without referral from primary care, however, you must visit doctors and hospitals within the EPO network. There are no out-of-pocket benefits, so you will pay the full amount if you go to a provider outside of your plan network. Providence Health Plan is known for its EPO plan in Oregon.
In essence, these plans don’t differ just on health plan cost but also the size of the plan network, ability to see specialist and coverage for out-of-network services.
Health Insurance Terms
What do all these health plan terms mean? We are here to help them make sense!
The amount you pay your health insurance company every month
The amount you pay for health care services before your health insurance company starts to pay. For example, a plan with a $2,500 deductible means you pay the first $2,500, and after you pay that amount of medical bills, you usually pay just a copay or coinsurance percentage while the rest is paid by your insurance company
A small amount you pay each time you use a specific healthcare service (this payment does NOT go toward meeting your deductible)
The amount you pay for healthcare expenses after your deductible is met. For example, if your plan has a $1,000 deductible and you have spent $1,000 on medical bills, your insurance will now start paying a predefined percentage of your costs and the remaining percentage is the coinsurance you are responsible to pay
The highest amount you have to pay for covered health care services in a plan year. Once you meet your out-of-pocket cost, your health insurance company pays 100% of the cost of covered benefits.
Here are some of the popular health insurance plans in Oregon:
Here is just a snapshot of the most popular health insurance plans in Oregon for individuals and families. Take note that there are even more plans depending on your area and you may ask us for further details and quotes.
Frequently Asked Questions about Individuals and Families Health Plans
How does Individuals and Families Health Plans differ from employer-sponsored health insurance? Individuals and Families Health Plans are purchased by individuals or families for their own coverage, while employer-sponsored health insurance is provided by an employer as part of an employee’s benefits package.
Can I switch my Individuals and Families Health Plan during the year? Yes, you can switch your Individuals and Families Health Plan during the year during the open enrollment period or if you experience a qualifying life event.
Do Individuals and Families Health Plans cover pre-existing conditions? Some Individuals and Families Health Plans may cover pre-existing conditions, but the coverage and terms may vary. It’s important to carefully review the plan’s terms and conditions before enrolling.
What happens if I lose my job and my employer-sponsored health insurance coverage? If you lose your job and your employer-sponsored health insurance coverage, you may be eligible for COBRA continuation coverage or you can consider enrolling in an Individuals and Families Health Plan.
Need Help Applying for 2023 Health Insurance?
With rising coverage rates, you need to find the best health insurance plan for you and your family. To see if you qualify for subsidy and financial assistance to reduce your healthcare costs, Health Plans In Oregon is here to help.
Getting the right information and signing up for the best health insurance plan for you might be complicated, but Health Plans in Oregon can answer all your questions and help you find the right health plan for your needs and get you covered!
Health Plans in Oregon offer free assistance for Oregonians to get the help you need to sign up for any Oregon health insurance. We are here to answer all your questions and give you affordable quotes.
Need help? Call Health Plans in Oregon: 503-928-6918. Our assistance is at no cost to you.
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