What types of health insurance are available?
There are 3 types of health insurance discussed below:
- Major Medical Plans
This type of policy is usually effective in covering serious illness or injury where costs are high. Hospital care, drugs
and doctors’ visits are usually covered. Most major medical plans are required to include essential health benefits under
the ACA. Essential health benefits include at least the following items and services:
- Ambulatory patient services – outpatient care you get without being admitted to a hospital
- Emergency services
- Maternity and newborn care – care before and after your baby is born
- Mental health and substance use disorder services, including behavioral health treatment – this includes counseling
- Prescription drugs
- Rehabilitative and habilitative services and devices – services and devices to help people with injuries, disabilities
or chronic conditions gain or recover mental and physical skills
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
- Limited Benefit and Supplemental Plans
These types of policies provide limited coverage for a particular health setting, ailment or disease. These plans do not have
the essential health benefits that are required for major medical plans under the ACA. Consider purchasing one of these plans
after you have a major medical insurance plan in effect.
Before you purchase a limited benefit or supplemental plan, please consider:
- Limited benefit or supplemental plans are not a substitute for comprehensive major medical coverage. Insurance
coverage for all conditions is essential.
- Some limited benefit or supplemental plans pay only for hospital care. Many treatments, such as for cancer
chemotherapy, are often given on an outpatient basis. Read the plan limitations and exclusions carefully.
- These policies will not cover conditions diagnosed or treated prior to your policy application. You may be subject
to preexisting condition limitations.
- Many policies have time or dollar limits. Some policies might have a waiting period of 30 days or more before
benefits are payable. Other policies may stop paying benefits after a fixed period of time or a certain dollar limit.
- Additional Coverage Options
Other types of policies provide added protection should you become disabled, require long-term care or enroll in Medicare:
- Disability Income – This coverage provides for weekly or monthly benefit payments while you are disabled after a
covered injury or sickness. The disability payment is usually a set dollar amount not to exceed a certain percentage
or your income. Your disability payments may be reduced by other income you receive, such as Social Security disability
or retirement benefits. These policies usually expire when you become eligible for Medicare.
- Long-Term Care Insurance – This policy usually pays for skilled, intermediate and custodial care in a nursing home,
and also for care in other settings, such as the home, adult day-care center or assisted living facility. The policy
usually pays a fixed amount per day while the person is receiving care. For more information on long-term care insurance,
contact our Senior Health Insurance Benefit Advisors Program (SHIBA) or call 800-247-4422. Also
see our page regarding the Idaho Long-Term Care Insurance Partnership Program.
- Medicare Supplemental Coverage – The federal Medicare program pays most medical expenses for people age 65 or older,
or for individuals under age 65 receiving Social Security disability benefits. However, Medicare does not pay all
expenses. As a result, you may want to buy a Medicare Supplement policy that helps pay for certain expenses, including
deductibles not covered by Medicare. For more information on Medicare and coverage options, contact our
Senior Health Insurance Benefit Advisors Program (SHIBA) or call 800-247-4422.
These are NOT health insurance plans:
- Discount Plans – You may receive advertisements from plans offering discounts on health care for a monthly fee. These are
not health insurance plans and participants do not have the same protections as under licensed health insurance plans. The
Department of Insurance strongly recommends that you thoroughly investigate any plan promising deep discounts for a “low” monthly
fee and weigh the benefits against the cost carefully
- Non-Licensed Risk-Sharing Plans – You may receive offers to join a group or association that will take your monthly premiums,
put them in a savings account (or trust) with other participants’ money, and then help pay some of your health care costs as
needed. Such arrangements are not insurance, and the participants do not have the same protections as purchasers of licensed
insurance plans. The Department of Insurance strongly recommends that you thoroughly investigate such plans before joining.
Why do I need health insurance?
The federal Affordable Care Act (ACA) requires you to have major medical health coverage in place or you may be subject to a
federal tax penalty. Penalties will be assessed by the Internal Revenue Service (IRS) at the time a federal income tax return
is filed. For more information about the tax penalty and about possible exemptions from the requirement to have health coverage,
please visit the IRS website .
For information on how to enroll in health coverage, contact Your Health Idaho
or an insurance agent or broker licensed to do business in Idaho.
What Dates Can I Purchase Health Insurance (Open Enrollment)?
Open enrollment dates are from November 1st through December 15th, for coverage beginning January 1st of the following year.
How can I get help paying for health insurance?
You can apply for health insurance through Your Health Idaho if you are not offered affordable health coverage through an employer.
You’ll be able to compare different health insurance options on the basis of price, quality and other factors. Depending on your
family income, you may be able to get help in paying for your monthly premiums and out-of-pocket costs, such as deductibles and
You will need to apply for health insurance during the annual open enrollment period, which begins in the fall of each year, for
coverage beginning January 1st of the following year (if your family has special circumstances, such as losing previous health
coverage, you may be able to enroll outside the open enrollment period). For information on open enrollment, getting help paying
for insurance, special enrollment periods, and details on how to apply, please visit
Your Health Idaho.
Should I buy health Insurance on-line?
Insurance plans that qualify under the Affordable Care Act should be purchased from an insurance agent/broker licensed to do
business in the state of Idaho. You can visit Your Health Idaho
to find agents/brokers or shop for insurance coverage on your own.
What happens when my group health coverage ends?
You can apply for individual health coverage through an
agent or broker in
the area where you live, or by contacting an insurance company offering individual major medical coverage in Idaho.
You must apply for individual coverage no later than 60 days after losing your group coverage. You may also apply for
individual coverage up to 60 days before your group coverage ends in order to make sure that the new coverage picks up
where the old coverage ends.
What happens to my group health coverage if I leave my employer?
You may be eligible for protection under the Consolidated Omnibus Budget Reconciliation Act (COBRA) and may be entitled to a
minimum of 18 months of continuation coverage. You can find out more about COBRA continuation of group health benefits from
the U.S. Department of Labor Office of Employee Benefits Security
Administration website or call 866-444-3272.
If your employer has less than 20 employees, you might not be eligible for COBRA. Idaho does not have any other continuation of
health coverage requirements if you are not eligible for COBRA. If you are moving to a new employer, you may have new group
health coverage available through your new employer. Otherwise, apply for an individual health insurance plan as soon as possible
so you have continuous protection.
What is a “self-funded” plan?
An employer may choose to “self-fund” the employees’ health plan by paying out benefits from its own funds. Typically, an
insurance company administers the program, but the liability for paying the care of the employees rests on the employer. Workers
should understand that if their employer “self-funds,” state protections (such as access to internal and external appeal
processes, assurance of certain benefits, and the right to have grievances heard by the Department of Insurance) do not apply.
All federal protections (i.e., HIPAA and COBRA) do remain. You can find out more about self-funded plans from the U.S.
Department of Labor Office of Employee Benefits Security Administration website
or call 866-444-3272.
Where can I go for help?
If you have questions about your policy, your rights and protections, or a potential agent or insurer, contact the Idaho
Department of Insurance at 208-334-4319 in the Boise area, or 800-721-3272 toll-free statewide. You can also contact the
Department for assistance if you have a grievance against a licensed health insurance company or agent/broker. You can file
a written complaint against a company or agent/broker here.
Was your question not listed here? Contact our Consumer Affairs section with your question.
Need more info? Contact us at 208 334-4319 or email us .
Consumer Affairs Officers are available to answer your questions 8-5 M-F MST