What is an individual and family health plan? A beginner’s guide for Pennsylvania residents

If you don’t receive health insurance through your employer, securing coverage can feel overwhelming…

When do I apply?

Where do I apply?

What do I need to apply?

The good news – you don’t have to do it alone. Capital Bue Cross is here to help.

This guide gives you basic information about individual and family health insurance. Whether you are looking for coverage for just yourself or you and your family, understanding the basics is the perfect place to start.

Get step-by-step help applying for coverage – at no cost to you.

Schedule an appointment or call 610.546.7504 for personalized support.

Let’s start at the beginning

Individual and family health insurance plans provide coverage you purchase on your own – outside of an employer or government program. They’re a great option for people who are self-employed, work part-time, don’t have coverage through their employer, or aren’t eligible for Medicare or Medicaid.

If you need coverage for more than just yourself, a family health insurance plan can include your spouse and children. These plans offer the same essential benefits as individual coverage but extend protection to your entire household – often at a more cost-effective rate than purchasing separate plans for individual family members. It’s a simple way to make sure everyone in your family can access the care they need, when they need it.

What is covered under an individual and family health plan?

All individual and family health insurance plans cover essential health benefits, ensuring you have access to necessary medical care. These services include:

• Pediatric dental and vision care.
• Preventive and wellness services as well as chronic disease management.
• Emergency services.
• Hospitalization.
• Laboratory services.
• Maternity and newborn care.
• Mental health and substance use disorder services.
• Prescription drugs.
• Rehabilitative and habilitative services.

How do I apply for coverage?

Whether you’re applying for health insurance for the first time or switching plans, Capital Blue Cross is here to help you through the process.

As a Pennsylvania resident, you can explore plans through Pennie, the state’s official health insurance marketplace. Pennie is a helpful resource, especially if you're exploring financial assistance – but it's not the only way to apply.

Why apply directly with Capital?

• A variety of plan options, including some that are not available on Pennie.
• Get a direct quote tailored to your needs.
• Receive personal guidance from licensed representatives who walk you through each step – no guesswork required.

Schedule an appointment or call 610.546.7504 for personalized support.

When can I apply for coverage?

It is important to know the times during the year when you can sign up, change, or renew your plans.

Open Enrollment Period (OEP)

The open enrollment period is the main window each year when anyone can apply for a new individual or family plan. For Pennsylvania residents, the open enrollment period runs from Nov. 1 through Dec. 15 for coverage starting Jan. 1.

During this time, you can enroll in a plan for the first time or switch to a different plan.

The open enrollment period is a great time to review your options and make sure your plan still fits your needs and budget.

Special Enrollment Period (SEP)

If you miss open enrollment, you may still qualify to apply during a special enrollment period, but only if you have experienced a qualifying life event. These events include:

• Loss of minimum essential coverage or loss of federal program eligibility.
• Gaining or becoming a dependent.
• Access to new individual plans due to permanent move.
• Change in eligibility for on-exchange coverage – losing advance premium tax credit (APTC) or cost-sharing eligibility only.
• Enrollment or plan error.
• Domestic abuse or spousal abandonment.
• Individual Coverage HRA (ICHRA).

Capital’s special enrollment period gives you 60 days (about two months) from the date of the event to apply for a new plan.

Key terms to know

Managing your health insurance coverage can feel overwhelming at first. Understanding a few basic terms can help you feel more confident when making choices for your health and budget.

Here are some of the most important terms to know:

• Premium: The amount you pay monthly for your insurance coverage.
• Deductible: The annual amount you pay out-of-pocket for covered healthcare services before your plan begins to pay.
• Coinsurance: The percentage of the cost you pay out-of-pocket for covered healthcare services after your deductible is met.
• Copay: A fixed amount you pay out-of-pocket at the time of service for covered healthcare services.
• Out-of-pocket (OOP) costs: Costs you pay for healthcare services versus what your plan pays for.
• Maximum out-of-pocket (MOOP): The annual maximum out-of-pocket costs that you or your family must pay for covered services.
• Network: A group of doctors, hospitals, and other providers your insurance plan works with. Choosing doctors in-network helps keep your costs lower.

Contact

If you have questions or need help choosing an individual or family health plan, call 610.546.7504 for assistance. You can also walk in or schedule an appointment at one of our Capital Blue Cross Connect health and wellness centers.

This is not medical advice and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment. The information provided is meant for a general audience. Capital Blue Cross and its affiliated companies believe this health education resource provides useful information but does not assume any liability associated with its use.