Individual Health Plans

We offer Qualified Health Plans (QHP) that were set by the Patient Protection and Affordable Care ACT (ACA) to individuals and families. Vision benefits are included with select medical plans. Dental insurance is available as a separate policy and can be purchased without medical coverage.

When choosing a medical or dental plan, there are primarily three things to consider: 1) providers, 2) benefits, and 3) rates. Provider networks basically define the three different types of plans available: Health Maintenance Organization (HMO), point-of-service (POS), and Preferred Provider Organization (PPO). If you currently have a doctor you are comfortable with, we want to find a plan that includes your doctor in their network.

Providers

An HMO plan provides services through a designated network of doctors, hospitals, labs, and other providers. To receive benefits, you must first see your chosen Primary Care Provider (PCP). The choice of doctors is most restrictive with an HMO plan. If you do not use one of the network's doctors, clinics, or hospitals, you will usually be responsible for the cost of services.

A POS plan is a type of managed care plan where you also must choose a PCP. The POS network is generally larger than the HMO network. To receive the highest level of benefits, most care must be received by your PCP or a specialist referred by your PCP. However, if you do not use a network provider, you will still be covered under the plan, but at a lower percentage.

A PPO plan includes the largest network of doctors, hospitals, labs, and other providers. To receive the highest level of benefits, most care must be received by a PPO provider. The plan allows you to self-refer to any PPO physician or specialist. Care received from a non-PPO provider is usually covered at a lower percentage. However, less than 10% of doctors in the State are non-PPO providers.

Benefits

All individual Qualified Health Plans (QHP) must cover the 10 “Essential Health Benefits” That were set by the Patient Protection and Affordable Care ACT (ACA). These benefits include:

Ambulatory patient services: Covers outpatient care without being admitted to a hospital.
Emergency medical services in an emergency department: Covers services provided in an emergency department if a medical provider believes the patient is having an emergency.
Hospitalization: Surgery and overnight stays.
Maternity and newborn care: Coverage for maternity and newborn health care.
Mental health substance abuse disorder services: Behavioral treatment, mental and behavioral health inpatient services and substance abuse disorder treatment.
Lab services: Such as blood draws or urinalysis, a medical provider orders.
Pediatric services: Health care for children from birth to age 19, including dental and vision care.
Prescription drugs: Medications a medical provider prescribes that patients buy through a pharmacy.
Preventive and wellness services and chronic disease management: Preventive services, such as shots and screening tests, at no cost to the patient when a medical provider from the plan's network delivers the service.
Rehabilitative and habilitative services and devices: Services and devices to gain or recover mental and physical skills for people with injuries, disabilities or chronic conditions.

Uninsured individuals and families do have the option to enroll on these plans once per year during the annual open enrollment period.

Rates

Individual plan rates are based on the type of plan (benefits), your age, your use of tobacco products and your Zip Code. Each age-bracket has a published rate for smokers and non-smokers. Qualified Health Plans have varying deductibles and out-of-pocket maximums (coinsurance maximum) depending on your specific needs and budget. A lower deductible plan will be more expensive as compared to higher deductible plans.

At Pacific NW Insurance Brokerage, we compare all plans available to find the plan that best fits your budget and protection needs. We will clearly explain the plan's benefits, exclusions, and limitations to make sure it is the right one for you. Throughout the life of the policy, your agent will be available to provide any service you may need regarding your policy.