Do I need health insurance?

You may think that neither you nor your family needs health insurance.   You may be right, but you won’t know until it’s too late!  Insurance is all about the future; things that will happen but we don’t know when or things that could happen but we don’t know what.

Of course, you can take the risk but just one visit to ER could cost over $1200, and treatment for chronic (long term) disorders such as diabetes or cancer will be in the $tens of thousands.

Unpaid medical bills are the greatest single cause of bankruptcy in the USA.

Health Insurance gives you the peace of mind to face these risks, knowing that you and your loved ones are protected.

Health insurance won’t cost you a fortune – but may save you one!

Must I have health insurance coverage?

Technically, yes. But there is, at present, no penalty for not having health insurance.  The Affordable Care Act (ACA) underwritten by the US government ( provides for subsidies and tax relief for about 80% of US families and in some states low income families qualify for free insurance under Medicaid.  It remains the individual’s responsibility to ensure that they are registered.

How do I choose a plan?

The health insurance market place covers all US residents so there are thousands of different plans designed to meet their differing needs.  You can of course go to a single insurance company (or ‘carrier’ so-called because it carries the risk).   If you choose one of these plans it will be ‘off exchange’ and you will not be entitled to tax relief on your premiums.

Alternatively, you have a choice of Health Insurance Exchanges. These Exchanges arerun either by the Federal Government, State Governments, (Federally Facilitate Marketplaces, FFM) or by Private health insurance exchanges. Policies purchased though any of these organizations are said to be ‘on exchange’ andwill qualify for tax allowances and other benefits if appropriate.

Based on your personal details the exchange (FFM or private) will:

  • Offer you a selection of health insurance plans
  • Estimate the subsidy you would receive
  • Advise you of any state variations which may apply

FFM may not offer a full range of health insurance coverage and do not take into account your broader spectrum of insurance needs.  For instance, most insurance companies (carriers) will offer favorable terms if you wish to include Hearing, Vision and other risks not covered by ACA.  For example, the costs of

  •  Hospital care
  • Homecare
  • Loss of income

Private health insurance exchanges offer this broader range of service, and can generally respond more promptly and take a more personalized approach.

They are not agents for or representatives of, any insurance company.  It is their role to explore the health insurance marketplace to find the best insurance deal… for you!

When should I apply?

You are obliged by law to have health insurance in place for yourself and your dependents by January 1st 2020.  Note. There is no penalty for not having a policy in force but if uninsured you will be entirely responsible for all medical and hospital costs.

You can purchase the plan that matches your needs best at any time between November 1st and December 15th 2019.

BUT you should start planning now.

There are 4 factors which will affect the cost of your coverage:

  • Income
  • Family size
  • Location (regulations vary from state to state)
  • Whether or not you use tobacco

To support these facts, you will need your Social Security number, and your most recent W2 or 1099. 

Finally, you should consider the type of plan which would best suit your expectations and your budget. (See the section; Compare plans).

What happens if circumstances change?

Some changes of circumstance justify changing your insurance coverage.  These are called ‘qualifying life events’.  Examples include a change in marital status, an additional dependent, an existing dependent reaches 27, a change of employment which results in a temporary or even a permanent loss of health insurance cover.  Contact your exchange or your insurer (off exchange).

What healthcare services are required to meet the terms of the ACA?

All health insurance available to consumers must cover ‘ten essential’ benefits which are:

  • Ambulatory patient services (outpatient care that does not need admission as an in-patient)
  • Emergency services
  • Hospitalization for surgery, overnight stays, and other conditions
  • Pregnancy, maternity, and newborn care
  • Mental health and substance use disorder services
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (the treatment and devices that help people gain or recover mental and physical skills associated with an injury, disability, or a chronic (long-term) condition).
  • Laboratory services
  • Preventative and wellness services, including chronic disease management
  • Pediatric services, which include dental and vision coverage for children

These are the 10 categories of services covered by all health insurance offered to consumers. The specific services offered within these categories may differ from state to state. Individual states may require that plans offer more comprehensive services to their customers. expect to find under these categories.

Your state, the federal, and private exchanges will be aware of the specific services which apply to your location. 

Preventative care

All health insurance plans on government-run marketplaces (ACA) offer preventative healthcare services, such as shots and screening tests.  These services are included in your monthly premium. Members.  Depending on your plan you may have to contribute the cost of further treatment. As of 2019, these are the 18 free preventative services for all adults, as outlined by

  • Abdominal aortic aneurysm one-time screening
  • Alcohol misuse screening and counseling
  • Aspirin use to prevent cardiovascular disease
  • Blood pressure screening
  • Cholesterol screening
  • Colorectal cancer screening
  • Depression screening
  • Diabetes (type 2) screening
  • Diet counseling
  • Hepatitis B screening
  • Hepatitis C screening
  • HIV screening
  • Immunization vaccines
  • Lung cancer screening
  • Obesity screening and counseling
  • Sexually transmitted infection prevention counseling
  • Syphilis screening
  • Tobacco use screening and cessation interventions

Note that some of these screenings may be free only for specific age groups. Discuss your plan with your Exchange or your insurer to check which preventative services are free for you.

Women and children have additional preventative care benefits.

For women, many of the free preventative care benefits are related to:

  • Pregnancy
  • Breast feeding
  • Contraception
  • Gender-specific cancers
  • Sexually transmitted diseases

For children, free preventative care is more concerned with:

  •  developmental disorders and behavioral issues
  • screenings for common chronic on-going illnesses


Thanks to the ACA the services covered by a qualifying health insurance plans are standard. You can be sure that both the service providers (doctors, consultants, hospitals, carers) and insurers or exchanges are performing their roles in a competitive marketplace.

Thanks also to the ACA, health insurance is made more affordable by federal and state subsidies.  Most US citizens (85%) feel the benefit of tax credits on their insurance premiums.  Many others, e.g. seniors, and the chronically ill receive free or subsidized care.

No health insurance company can refuse to insure you but YOU have a choice about how to share the cost.

Your monthly premium entitles you to the services described above (free of charge) but there may be other expenses, eg prescription drugs, doctors’ visits, lifesaving surgery or cancer treatment. In addition to your monthly premium you will have to pay a proportion of these costs.

All plans will offer the 10 benefit categories but they are grouped into 4 different tiers  The tiers do not define the quality or level of service they are a straight forward way of describing how you want to share the costs of insurance with your chosen carrier.


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