Individual & Family Health Insurance Basics
If you don't have health insurance options through your job or a state- or federally-funded program, like Medicare or Medicaid, it's time to look into your individual and family health insurance options.
Affordable Care Act (ACA) basics
Signed into law on March 23, 2010, the ACA made health insurance available to all Americans. Here's what you need to know about all ACA, or individual and family, plans:
- Guaranteed Issue: No one can deny you coverage based on your health status.
- Essential Health Benefits: A set of 10 health care service categories that health plans must cover.
- Open Enrollment Period: A specific time of year you can purchase health insurance for the upcoming year. You can enroll outside that window if you experience a special enrollment period, like marriage or birth.
- Tax penalties: In 2017, Congress eliminated the tax penalty associated with failing to have health insurance. This became effective in 2019.
- Summary of Benefits and Coverage: This important document gives an overview of your plan and coverage options.
Questions about individual and family insurance? We have answers.
On March 11, President Biden signed the American Rescue Plan Act (ARPA) Act of 2021 into law making it easier to access affordable health care coverage through the Health Insurance Marketplace.
Beginning April 1, 2021, the new law will help lower premiums for existing members and deliver more affordable plan options to new members who are enrolled in Marketplace coverage. With this new law, no household will pay more than 8.5 percent of their household income, which means most consumers will be eligible for a higher tax credit to lower their premium. In short, the ARPA is expanding the number of people eligible to save money on their health care coverage obtained through the Health Insurance Marketplace.
For more information on the ARPA, please see the fact sheets provided by Center for Medicare and Medicaid Services and the U.S. Department of Health and Human Services linked below.
If you are a current Wellmark member and your premium changes due to the American Rescue Plan, it will take time for your new premium to be reflected on your Wellmark bill. The amount of time it takes depends on multiple factors, but most premium updates are completed within 30 days.
We recommend all members continue to pay the premium amount listed on their bill, so they do not experience any coverage disruptions. Once the premium amount has been updated within Wellmark, any overage paid by you will be reflected as a credit on your next bill.
Members can make plan changes or see if they qualify for a higher tax credit by visiting Healthcare.gov External Link directly or calling the Health Insurance Marketplace at .
This is a great place to start! We will walk you through everything you need to know about individual and family health insurance.
There are several ways to purchase health insurance. Some people get it through their employer or qualify for it through a federal- and/or state-funded programs, like Medicaid. If you don't get insurance from your job or qualify for Medicare or Medicaid, you should look into ACA-compliant individual and family plan options.
Just like the name implies, individual and family plans can cover a single individual or include their spouse and kids. These plans are available at different price points and coverage amounts to fit your specific needs.
You can buy an individual and family plan from a private health insurance provider, like Wellmark Blue Cross and Blue Shield, through HealthCare.gov External Site, the federal Health Insurance Marketplace. See our plan options and enroll online or call a Wellmark-certified agent to help you find a plan that fits your needs and budget.
Wellmark is not offering new individual and family plans in South Dakota for 2021. But you still have options.
Auto-renew your plan
If you are on a current pre-Affordable Care Act (ACA) plan and wish to renew for 2021, there is no action needed. Your health plan will automatically renew for 2021 so you can continue to keep the coverage you have come to know and trust. You'll receive more information about your 2021 health plan in your renewal letter this Fall.
If you are looking for a different health plan, you should talk to an agent about your options or visit HealthCare.gov External Site. Keep in mind, if you cancel your grandfathered or grandmothered plan, that same plan will not be available to enroll in again.
When it comes to picking the right plan, everyone has different preferences. Shopping for health insurance is easier when you know what you want from a health plan. By answering these questions, you can feel prepared to pick an individual or family plan that fits your needs.
Who do you need to insure? Is it just you? Or, do you have a spouse and children who need insurance, too?
What is your monthly budget? Take a look at what you’re currently paying for health insurance and if that is working with your budget. You could be eligible to receive a subsidy Glossary popover to reduce your healthcare costs. Your Wellmark agent can help you check your eligibility or you can see if you qualify for a subsidy by visiting HealthCare.gov External Site.
What's important to you in a plan?
- Network — If seeing the same doctor or receiving care that's close to home is important to you, you should pay close attention to the size of a plan's network Glossary popover. The broader the network, the more coverage you will have when you're away from home.
- Benefits and coverage — Health insurance plans cover a lot of services, but how much you pay out-of-pocket varies by plan. You may prefer a predictable copay with each health care provider visit or you might prefer contributing to a health savings account to cover future medical expenses.
- Value and cost — You may be shopping solely based on price. But, it's important to keep in mind the value you get from your plan through no-cost benefits like discount programs for members or 24-hour nurse lines. Wellmark has these benefits and more!
5 steps to choosing the right individual or family plan
- Figure out what you need from your plan. See Wellmark's individual plans online.
- Pick your metallic tier Glossary popover.
- Check your premiums, cost shares, etc.
- Make sure your doctors are covered under the network and your drugs are on the formulary.
- Check out the extra no-cost benefits.
When you've decided which plan best suits you and your family's needs, you can enroll in that plan online at HealthCare.gov External Site.
Want to talk it over? When you speak with a certified Wellmark agent, you’ll get advice from someone who knows health insurance inside and out.
Signing up for health insurance usually happens every year during Open Enrollment between Nov. 1–Dec. 15. It's important to sign up at this time to avoid any gaps in coverage. After you enroll, you'll be able to start using your plan on Jan. 1.
You can still apply for health coverage outside of Open Enrollment if you have certain life changes, like marriage or a loss of employment, during a special enrollment period. These changes are called qualifying life events.
Where to sign up
After you've compared Wellmark's individual health plan options and decided which plan best suits all your needs, you enroll in that plan online at HealthCare.gov External Site, the federal Health Insurance Marketplace.
If you would rather not enroll online, you can call a certified Wellmark agent. Your agent will talk through the plan options with you and can easily enroll you in person or over the phone.
It's new! Due to an executive order, enrollment will reopen February 15—August 15, 2021. Your coverage will start the first month after you've selected a plan. Think of this enrollment period like the Open Enrollment period that starts Nov. 1 — you have all the same choices! With this special enrollment period, you can:
- Enroll in a federal Health Insurance Marketplace plan on HealthCare.gov External Site if you haven't already.
- Change from another carrier to a Wellmark individual and family insurance plan.
- Switch to any available plan on the Marketplace.
To enroll in a new plan, you will need to have a few things ready to start your application:
- Basic information: Provide your name, date of birth and home address.
- Household information: Be prepared to provide basic information for each person in your household, even for those not applying for coverage.
- Social Security number: Have the Social Security number handy for you and everyone you want covered under your health plan.
- Household income: Provide the best estimate of your household income. This is important as it will determine if you are eligible for a subsidy to reduce your health care costs.
- Agent number: If you're working with an agent, make sure to include their agent number (NPN). If you're unsure of this number, contact your agent for help.
If you've already completed your application from a prior year, be sure to make any needed updates to your application before enrolling in a new plan.
Unfortunately, Wellmark doesn't offer dental or vision coverage for individuals and family plans at this time.
Yes, drug coverage is included. Every Wellmark ACA individual and family plan comes with the Blue Rx EssentialsSM formulary, which makes your pharmacy benefits easy to navigate. With Blue Rx Essentials, you'll know exactly what your drugs cost ahead of time, without any surprises.
Search the Blue Rx Essentials drug list External Site to check the costs for your current or planned prescriptions.
There are several ways Wellmark stays in touch with you.
Soon after you enroll, you will receive a welcome letter telling you when to expect your ID card in the mail. Typically, your ID card arrives 10 business days after receiving your welcome letter.
Your welcome letter will also detail how to enroll in your personal health care portal, myWellmark®. With myWellmark, you'll be able to:
- Pay your premiums with a one-time payment or recurring payment schedule.
- Check the status of your health claims at any time.
- Track health care costs and run reports to see how much you've spent out of pocket.
- Find out what is covered and how much your plan will pick up for certain services.
- Compare prescription prices.
- Get digital Explanation of Benefits (EOB) statements and sort them by date, provider or patient.
- Get your ID card digitally. Print it out or order a replacement card with the click of a button.
We will keep you informed of any important plan updates through a variety of ways, including email, Customer Service, myWellmark or by mail.
We are always available to help you. You can contact Wellmark by calling Customer Service at the phone number listed on the back of your ID card. Or, use the Ask and Track a Question feature in myWellmark.
You can't control when you get sick or injured, but you do have options when it comes to lowering health care costs.
Get help paying for your plan
Find out if you qualify for financial assistance, sometimes called subsidies Glossary popover, on HealthCare.gov External Site. This can help reduce monthly premiums or cost-shares for people with lower incomes.
Take advantage preventive care services
Did you know all individual Affordable Care Act (ACA) health plans are required to cover preventive care services at no cost to you? Take advantage of this benefit by getting an annual preventive care exam every year.
Use the free stuff
A health plan is more than just coverage for doctor's visits. It's about your overall health and well-being. With Wellmark, you'll get extra value at no cost to you with benefits such as:
- myWellmark: With myWellmark, you can manage your health, health plan and health care costs in one place.
- Blue365®: Blue365 offers exclusive access to discounts and resources like gym memberships and fitness equipment like Fitbit® and Garmin®.
- BeWell 24/7SM: Get your health insurance questions answered at any time of day. Everything from finding a provider to estimating the costs of an upcoming surgery.
- BlueSM: Get helpful real-life examples on how to get the most from your benefits and live a healthy, full life online at Wellmark.com/Blue opens in new window.
Blue365® is a discount program available to members who have medical coverage with Wellmark. This is NOT insurance.
Blue365® is a registered mark of the Blue Cross and Blue Shield Association.
Save money and make smart decisions with myWellmark. myWellmark is your one-stop source for pharmacy tools.
- Find savings and opportunities: Discover easy ways to save on your medicine and find lower-cost drug options.
- Learn about your prescriptions: Check drug interactions, generic alternatives and stay informed about your prescriptions.
- Search for a pharmacy: Depending on your network, you may be able to choose from more than 60,000 pharmacies, including the ones nearest to you.
- Use no-cost mail-order and specialty drug services: Save time and money by using mail order pharmacy for the prescriptions you take regularly. Or, receive specialty drug services when you use a preferred pharmacy.
Want to know your drug costs? It's simple.
- Log in to myWellmark.
- Click on the Find Costs link and select Drug Costs.
- Type in a drug name and choose a pharmacy to see the out-of-pocket cost based on your benefits.