Individual Health Insurance Options

There may be reasons people will need a private or individual insurance plan. For example, if you do not have health insurance through your employer, if you are in between jobs or insurance plans, or if you want to learn about other options or maybe are considering supplemental insurance. Whatever the reason, there are options to get insurance. Some are available only for people in special circumstances. 

What you need to know about individual health insurance 

• People with lower incomes don’t get help with cost reductions or premium payments on non-Marketplace plans; these cost savings are only available on Marketplace plans.
• Non-Marketplace plans that cover children may allow young adult children to be covered up to age 26 (as do Marketplace plans)
• Even though the federal government no longer requires you to have health insurance, some states still do. A few non-Marketplace plans might not meet the requirements for minimum coverage in some states. You can learn more about your state's insurance requirements at healthinsurance.org
• Scammers will try to take advantage of people who might be looking for insurance coverage

Health insurance from the state Marketplace (Affordable Care Act)

Under the health care law, people looking for health coverage will be able to compare plans and select the best one for them from online health insurance Marketplaces in each state. Your state’s Marketplace will collect information from you to find out if you qualify for Medicaid (or if your child is eligible for your state’s Child Health Insurance Program, called CHIP) or financial help to pay for coverage. Visit healthcare.gov or CuidadoDeSalud.gov for your state’s information.

Health insurance for immigrants

In most states, undocumented immigrants are not eligible to enroll in Medicaid or CHIP or to purchase coverage through the ACA Marketplaces. Lawfully present immigrants may qualify for Medicaid and CHIP, but are subject to certain eligibility restrictions.

Lawfully present immigrants can purchase coverage through the ACA Marketplaces and may receive subsidies for this coverage.

 For more information go to Immigration Status and the Marketplace.

Health insurance for travelers from other countries

For visitors to the United States, travel insurance can offer protection from medical emergencies. While no visitor medical insurance plan covers pre-existing conditions (such as cancer), there are some plans that provide coverage for acute onset of pre-existing medical conditions up to a certain limit.

More information can be found at  U.S Department of State: Insurance Providers for Overseas Coverage.

Health insurance through an Association Health Plan

Association Health Plans (AHPs) are group health plans that employer groups and associations offer to provide health coverage for employees. AHPs allow small employers to band together to purchase the types of coverage that are available to large employers, which can be less expensive and better tailored to the needs of their employees.

Rules governing AHPs continue to change, so check for current information.

Considerations about health insurance coverage for people with cancer

It's important to read your health insurance's Summary of Plan Benefits (SPB) to be familiar with the services your plan covers and excludes. It's also helpful to review the list of services that may require pre-approval or prior authorization. Talk with your cancer care team to help you find your answers.

Cancer tests (PET/CT scans, blood tests, bone scans: These can include lab or imaging tests and procedures. Several of the tests typically require pre-approval or prior authorization by your insurance company before starting the services.

Inpatient (a stay in a medical facility) and outpatient care: Your insurance's summary of plan benefits (SPB) will explain pre-certification for care or services that are done in an inpatient or outpatient setting.  These services may include cancer, screening tests, diagnostic tests, or cancer treatment/therapy. Talk to your health care provider if you have questions about insurance coverage for these services.

In some insurance plans, cancer therapy (chemotherapy, radiation, or outpatient infusion) may be called specialized care. Cancer clinical trials may be called experimental or investigational treatment in some insurance plans. Your doctor may also order an oral chemotherapy drug for your cancer therapy. Oral chemo drugs can cost a lot depending on the type of drug and how new it may be. Talk to your health care team about what your health or prescription drug insurance will cover and how much you can expect to pay for each treatment.

Routine Cancer Screening or Diagnostic Tests:- Routine cancer screening tests are used to find cancer before a person has any symptoms. Diagnostic tests are different from screening tests because they usually are done to check out a symptom you are having or are done to follow up on an abnormal test result. Talk to your health care team about concerns you may have about insurance coverage and costs of these tests.

Some examples of diagnostic tests are: a doctor ordering a colonoscopy because of a patient has rectal bleeding or repeating a mammogram to follow up on an abnormal result. Some helpful questions to ask your doctor about screening tests include:

• Why is this test being ordered? Is it considered routine or diagnostic?
• What health risks are involved if I do not get this test?
• Will you get medical pre-approval or prior authorization from insurance (if it is required for this test)?

Genetic Screening: Your cancer care team may use genetic screening (also called genetic testing) to help reduce your cancer risk and find the best treatment. This screening is not an "at-home" genetic testing kit. Instead, this is an outpatient procedure that often requires pre-approval by your insurance company. Your team will work with certified genetic counselors to help you understand what to expect before your screening and also take time to discuss the results with you. Find more information about genetic counseling in What Happens During Genetic Testing for Cancer Risk.

Medical Equipment or Supplies: Your cancer care team may ask you to rent or purchase medical equipment for your home to help with your care. This equipment typically requires pre-approval by your insurance company. Coverage for this equipment may be explained in your health insurance's Durable Medical Equipment section in your SPB. Some examples include chemotherapy infusion pumps and supplies, commode chair, cane, hospital bed, walker, or wheelchair.

Sometimes medical supplies ordered by your care team are known as Disposable Medical Supplies. These items are typically used once and disposed of (on the other hand, durable medical equipment is used long-term and can be reusable). Examples of disposable medical supplies include gloves, incontinence products, blood testing strips, needles). Health insurance plans may have different coverage for disposable supplies and some supplies may be partially covered or excluded from your plan.

Talk to your cancer care team about questions you may have about your insurance coverage for tests and medical supplies.

Wigs: Your cancer care team may write you a prescription for a cranial prosthesis or hair prosthesis For more information, see Choosing and Wearing a Wig . 

Nutritional supplies: Your insurance plan may cover these supplies under certain medical circumstances. Examples of these supplies include nutritional drinks or feeding supplies prescribed by your cancer care team. Supplies at a grocery store (or commercially available products online) are typically excluded from insurance plans. Talk to your care team about different patient programs that may be available to help you cover these expenses.  For more information, go to U.S. Food and Drug Administration .

If you want to learn more

Along with the American Cancer Society, other sources of information and support are listed below.*

US Department of Health and Human Services, State Health Marketplaces & more
Toll-free number: 1-800-318-2596 (also in Spanish)
TTY: 1-855-889-4325
Website: www.healthcare.gov

Provides information on the new insurance law, takes you through the steps of finding insurance, and much more. If you don’t have Internet access, the phone number will help you connect with your state’s Marketplace to sign up for a plan

You can learn about hardship exemptions (which allow some people to avoid the penalty for not having health insurance).

US Department of Health and Human Services

Medicaid
Toll-free number: 1-877-696-6775
Website: www.medicaid.gov

Medicare 
Toll-free number: 1-800-633-4227
TTY: 1-877-486-2048
Website: www.medicare.gov

Your state social service or human service agency can give you the best answers to questions about your benefits, eligibility, and fraud. You can also read more on your state’s Medicaid website.

Answers questions, provides literature and gives referrals to state Medicare offices and local HMO’s with Medicare contracts.

*Inclusion on these lists does not imply endorsement by the American Cancer Society.