(That pic is my son on a day when our health insurance was the last thing on my mind. He’s fine.)
We have a lot of health insurance for single moms in America. Bronze plans, Platinum plans, HRAs and PPOs up the wazoo. Most of it expensive! The Good News: you’re more likely than ever before to qualify for assistance.
In this post, I’ll explain how health insurance works and how to choose a plan through your employer or in the private market.
And while I wrote this post for Single Moms, it’s really for any mom, like me, who has to figure this out every year.
If you want to learn more about insurance, and why I think it’s the bedrock of a financial foundation, check out my post on Life Insurance for Single Moms and, even more important, Disability Insurance – Worth it? Our megapost on Affordable Insurance for Single Moms is also fun!
What Is Health Insurance?
Health insurance policies help pay the high costs of healthcare services. This includes everything from preventive health screenings, prescription medications, dental procedures, and medical emergencies. Some health insurance plans also offer additional benefits like vision and alternative medicine (like acupuncture).
What Does Health Insurance Cover?
Thanks to the Affordable Care Act (ACA), ten essential benefits that must be covered by health insurance plans sold on the federal marketplace include:
- Outpatient care
- Emergency care
- Hospitalization, such as my son’s recent trip to the burn unit
- Pregnancy, Labor and Delivery, and care for mom and baby before and after birth
- Mental health and addiction services
- Prescription drugs
- Services and devices for people with disabilities
- Laboratory testing
- Preventative and wellness services, like your WellBaby and WellWoman visits
- Pediatric medical, vision and dental care
How Women Should Compare Health Plans
We have insurance because we expect to use it, so thinking about how you might use it can offer super useful guideposts to compare plans. Find these in the plan’s Benefits Summary Document.
What Will Checkups and Well Baby Visits Cost?
One of the secrets of healthcare is that preventive care actually keeps overall costs down. Checkups provide your kid with Important coverage such as vaccines required for school and screening for rare childhood cancers (this has hit two of my friends). Many health insurance plans offer preventive care at zero cost to the policyholder so you may not have to pay anything at all.
How Much Will An Emergency Room Visit Cost?
This is an important one to know, because it can vary A LOT. Depending on your plan, a trip to the ER might cost $100, your entire deductible or you could pay the whole damn thing out of pocket. My tricky toddler “helped” with tea and maxed out our plan on January 3rd this year.
Having a baby is similar math – it’s a hospital visit that can range from almost nothing to several thousand dollars depending on your plan.
What Will a Well Woman Visit Cost?
Did you know that most women receive all their medical care through their OB/GYN? Aside from taking care of your coochie, low out of pocket payments for well-woman visits will keep you healthy. According to Planned Parenthood, “This visit can cost anywhere from $35–$250.” Additionally, if you have insurance, birth control is free. #LoveYouObama
What Will My Maintenance Medications Cost?
For example, here’s mine:
- Birth control: Zero.
- Thyroid med: $20/month
- Advair: $600 per inhaler
If you take medication every month, make sure to check the plans “prescription formulary”. Usually this is broken into tiers, and each tier has a different price structure, with generics being cheaper and things like chemo being expensive. I’ve been on Synthroid for 12 years, and during that time it’s cost between $5-40 per month on a PPO. That’s $60-480 on an annual basis. It matters.
What is the Max I Will Have to Pay in a Year?
I cover how to calculate this more below, but don’t buy unless you know the answer and you are willing to risk it and beg for a payment plan or you can afford it. When they told me in the ER that they were transferring my son to a different hospital to stay in the burn unit. I knew we were going to max out our plan ($22000 in our case, because I am on a high-deductible plan). But you want to know BEFORE you’re in that moment, what you’re going to do about it. The max out of pocket number should either guide your emergency fund savings, or prepare you for managing medical debt (in which there is no shame. None.)
What am I **Likely** To Pay This Year?
Aside from the “Max” number, you should also know a ballpark of what you’re going to pay. We had the same plan last year and came nowhere near the deductible limit because most of what we used was preventative medicine or fully covered. Our normal is a lot of wellbaby visits and some urgent care (two ticks), a back specialist and my beloved endocrinologist.
The likely number is important, because it can help you judge the risk of your deductible. That deductible payment could be high, but the probability is it won’t be.
EMPLOYER-PROVIDED HEALTH INSURANCE FOR MOMS
If you can get health insurance coverage through your employer, it is likely cheaper unless you earn a low income and qualify for a high subsidy on the government marketplace. In most cases, you’ll be looking at much wider coverage and much lower premiums than you’d be able to qualify for privately. Employer-provided insurance is usually a better deal, but it can vary a lot, so be sure to take the time and check out what your employer’s policy will actually cover.
If your employer’s offerings suck, you might do better on on the healthcare marketplace, especially with the ARPA subsidies – but also check out policies offered through unions or professional organizations. A lot of major industries have preferred group rates on insurance, so even if your actual job lets you down, other pros in your field might have your back!
THE HEALTH INSURANCE MARKETPLACE FOR MOMS
If the options through your work won’t cut it–or if you’re self-employed–then you’re going to have to buy a plan yourself. You can work directly with an insurance broker, but I STRONGLY recommend you start with the health insurance marketplace at Healthcare.gov. You can purchase coverage for yourself only, just your kids, or for everyone in your household.
The prices will vary a lot from state to state, but across the board the plans are ranked as Bronze, Silver, Gold and Platinum. These metal categories determine how you split your costs with your insurer. For example, bronze plans typically have lower monthly premiums and higher out-of-pocket costs than the other tiers, and platinum plans tend to have the highest premiums with the lowest out-of-pocket costs.
The monthly premiums are low, but your deductibles and co-pays are high, meaning you may still be on the hook for a lot of money if you run into unexpected health issues. These plans are better than nothing, and they may be the right choice if you and your family have generally low medical needs and a tight budget.
These plans are the next step up, meaning you’ll pay a little more month-to-month for your premiums but you won’t be hit as hard on your deductibles or your co-pays. If you can afford the higher premiums, these plans may offer more coveragel for your family’s regular medical expenses and to insulate you a little better from unexpected costs.
Gold plans are more expensive in monthly premiums, but they offer better coverage for your care and lower out of pocket costs when you use it. These are a good choice for single moms who can afford to take the guesswork out of insuring their families.
Like the name implies, these policies are the best–and they come with a monthly premium to match. For a higher premium, you’ll be covered for much more, while appointments and prescription refills will have very low co-pays. Your preventative care (like well-baby visits, vaccines and generic prescriptions) likely won’t cost anything out of pocket at all–phew!
SHORT-TERM HEALTH INSURANCE FOR SINGLE MOMS
Don’t get stranded without insurance!
While it would be nice if your career was just one long interrupted string of paychecks and seamless coverage, it doesn’t always shake out that way. So if you’re between jobs or waiting or your employer-provided coverage to kick in, you can cover the gaps with a short-term plan. These policies are a stop-gap measure, so they’re definitely not as good as full-on health insurance–but they can be a real lifeline for you and your family if things hit the fan while you’re in transition mode.
COBRA stands for Consolidated Omnibus Budget Reconciliation Act–but for our purposes, it means coverage you can keep if you change jobs. For 102% of the premium (that’s the amount you were kicking in, the amount your employer was kicking in, plus an extra 2% fee to cover the administrative costs) you can continue with the insurance policy you already had, which can make a big difference if you’ve already paid a lot toward your deductible and your out-of-pocket limits and don’t want to start out at zero again. COBRA can make a big difference if you’re pregnant or in the middle of a course of treatment, but it can also be pricey–so shop around to be sure you’re actually getting a better deal.
Side note: I hate snakes.
HOW TO CALCULATE THE TOTAL COST OF HEALTH INSURANCE
Now that we’ve gone through all the options, it’s time to get down to the math. You’ll need to figure out three major numbers: your monthly premium, your deductible, and your out-of-pocket maximum.
This is your monthly bill, basically–the amount that the company charges you every month to be insured. Your insurer uses a variety of factors to come up with this number, but your age and your place of residence are the big ones.
The deductible is the amount you’re required to pay for on your own before the insurance coverage kicks in. For example, if your deductible is $1500, you’re on the hook for the first $1500 of healthcare expenses. Once you’ve paid your deductible amount for the year, your insurer starts paying for the rest.
CoInsurance and the Out-of-Pocket Maximum
How is coinsurance different from a deductible? It’s that line on the bill that says “Patient Responsibility.” It’s basically whatever is over their negotiated rate, or your coinsurance rate. Once you pay up to this amount, the insurance company will start paying for all of your covered expenses. Additionally, not all policies have coinsurance, so see if yours does.
Total Cost = All Your Premiums + Deductible and CoInsurance You Pay…
…Up To the Out Of Pocket Max
The most you will pay in a year is your out-of-pocket max, plus your premiums. My kid spent the first five days of 2022 in the ICU burn unit (he’s fine), but aside from a catastrophe, it’s hard to hit your out-of-pocket max. A good rule of thumb is to look at your last two years and see what you actually used. It then becomes much easier to pick a plan.
SHOULD MOMS JUST INSURE THEIR KIDS?
Ugh. I’m so sorry this is on your mind! I vote no. As a single mom, you are the bedrock of your household. If you don’t get the care you need, your whole family will suffer more. You can’t care for others if you don’t care for yourself, and neglecting your health to protect your family will end up hurting all of you in the long run.
Keeping everyone minimally insured is a financial priority above saving for retirement, saving for college, going on vacation, or splurging in any way. Budget for yourself and your health. Basic coverage is a top priority.
Premium Tax Credits And Payment Assistance Through Healthcare.Gov
Thanks to the American Rescue Plan Act, federal subsidy of healthcare opened up dramatically. 21.8 Million people are eligible for federal health care assistance, with 63% of uninsured people in 2021 eligible for subsidy. Does that mean it’s free? No. But ARPA radically increases the options for single moms on a shoestring budget.
Health insurance tax credits are financial help that comes from the federal government, which help to lower the cost of your monthly health insurance premium. That’s why they are specifically referred to as premium tax credits. To be eligible for a premium tax credit, you need to have a household income that’s below 400 percent of the federal poverty level (FPL).
When you apply for coverage in the Health Insurance Marketplace or your state health insurance exchange, you’ll find out if you qualify for a “premium tax credit” that lowers your premium.
The credit is based on your income and family size, but you make more than this, you may still qualify for financial help when you apply for insurance through the government sites.
If you qualify, the marketplace can send your tax credit directly to your insurance company to offset your premium, so you’ll pay less each month. This is called taking an “advance payment of the premium tax credit.” Or, you can receive the payments in one lump sum when you file your tax return.
If you end up making more money than you expected (yay!), you may have to pay some of the advance payments back when you file your taxes. If you end up making less, you may get additional money back as a tax refund or credit.
Best Health Insurance Plan Types
Beyond the options we went over above, there are some more specifics to get into when it comes to selecting your plan. You’ve got HMOs, PPOs, HDHPs, EPOs, POSs and HRAs to consider. You’ve probably heard a lot of these acronyms before, but don’t get overwhelmed by all the options! Let’s break them down.
HMO: Health Maintenance Organization (Think Kaiser)
HMOs offer plans where you have to go to specific doctors and hospitals in their system, except in an emergency. If you stay in-system, your preventative care is free, and out-of-pocket costs for big-ticket items (the ER, Cancer surgery, having a baby) are extremely low. Like $100. Total. This is a great option because it’s very predictable. Your costs will mostly be your premiums.
If you go out of network without a referral, you will be responsible for 100% of your costs. And you have to have a referral for a specialist – everything is managed by the network, so this is called “managed care.”
Many women who plan to have a baby choose HMOs because they’re usually the cheapest option.
PPO: Preferred Provider Organization (Think Aetna)
This is a plan where they prefer you go through a specific network of doctors and hospitals, but you have more choices than with an HMO. If you work with a major insurance carrier, you typically have a lot of choices, make sure they are in the PPO network.
This plan prefers that you stick with their specific network of healthcare professionals, but you don’t have to the way you do with an HMO. You’ll have a bit more wiggle room with these plans, but you’ll still want to double-check a lot of details to be sure the network covers the services your family actually needs (and that you won’t be paying way too much if you have to go to an outside provider!).
HDHP: High Deductible Health Insurance Plan (Also Aetna, Etc.)
HDHP Plans are PPO plans, but they offer an extra-high deductible, lower premiums, and another option: putting money aside into a tax-free investment account. These are a great option if you can afford the higher deductible, and they’re very efficient tax-wise if you’re looking to invest. But you’ll want to consider their options–they can be risky…
First, you are exposed to a higher deductible and out of pocket max. The minimum deductible is $2800 for a family, and $14,000 out of pocket max, also minimum. It can go up from there (mine does).
Second, with an HDHP, you can invest in an HSA (so there’s risk with how you do that) and you can’t use it for anything other than medical expenses, until you’re 65, without a penalty. An HSA an extremely tax-preferred investment account that I love and use.
EPO: Exclusive Provider Organization
An EPO is similar to an HMO, in that services are covered only if you services in the plan’s network (except in an emergency). However, unlike an HMO, you don’t need a referral to see a doctor. It’s usually cheaper than a PPO and you often have access to a wider array of doctors. Higher deductibles than an HMO.
POS: Point-of-Service Plan
A Point-Of-Service Plan is very similar to an PPO, except everything needs to go through your Primary Care Physician. She’s your “Point” of service. On the plus side: no deductibles.
HRA: Health Reimbursement Arrangement
This is what’s considered supplemental coverage, meaning it’s not usually a stand-alone policy, but it can be an amazing support if you have a high deductible on your regular insurance. A lot of small or nonprofit employers use HRAs to add a little extra to their benefits offerings. It helps cover your up-front costs before you’ve hit your deductible, meaning the amount you end up paying out-of-pocket can be even less. It’s usually an opt-in thing with your employer, so check with your benefits person to find out what the tradeoff looks like for you.
HELP FOR SINGLE MOTHERS WITH NO HEALTH INSURANCE
Maternal and Child Health Block Grant
This is a grant–meaning money given to you and you don’t have to pay anything back–from the federal government. You may qualify to have healthcare expenses covered for your children, or for yourself if you’re pregnant, if your income is at or below 200% of the federal poverty line. The exact amount varies every year depending on the economy and the size of your family, so check to see if you’re eligible.
Medicaid and CHIP (Children’s Health Insurance Program)
If your income is low enough, you may qualify for Medicaid or the Children’s Health Insurance Program (CHIP). These government-sponsored health insurance programs offer free or discounted coverage to people with qualifying incomes. The threshold for qualification is low, however. You can find out if you qualify by visiting Insurance.gov or filling out their pre-screening tool. Your state may have better options.
If you’re really struggling to make ends meet, your income may be low enough to qualify you for Medicaid or the Children’s Health Insurance Program (CHIP). Your income will need to be low to qualify, but you might get for free or discounted coverage for you and your kids. You can use the pre-screening tool at insurance.gov to see if you’ll qualify–but be sure to check what’s available at the state level too, as your state might have better options for you.
You can find out how much you’re eligible for by filling out a Health Care Marketplace application.
Partnership for Prescription Assistance
This is a program that works with pharmaceutical companies to negotiate on behalf of low-income patients. You’ll need to reach out to them directly, but if you’re eligible based on your income and certain other requirements (it can vary based on the drug) you may qualify for discounted or even free medications.
Vaccines for Children Program
As the name implies, this program provides vaccines for children! If your kids are 18 or younger and uninsured, Medicaid-eligible, Native American and/or Alaskan Native, they may be eligible to receive their vaccinations free of charge.
Consolidated Health Centers Program
This program delivers free or low-cost healthcare services to underinsured and uninsured patients at specific facilities in areas that are considered medically underserved. There may be CHC facilities in your area that you and your family can access for free or low cost. Find one near you here: https://findahealthcenter.hrsa.gov/
Your Parent’s Health Insurance
A lot of insurers will let you stay on your parent’s insurance policy as a dependent until you turn 26, which can be a great way to stay covered as long as possible–but it won’t cover your kids. You’ll need to insure your kids separately.This could be a good short term solution until you can all get on the same plan.
How Much Does Health Insurance Cost?
According to HealthCare.gov, five things can increase your monthly premium:
- Your age
- Your location
- Tobacco use. Smokers can pay 50% more than those who don’t.
- How many family members are on your plan
- Your plan category (bronze, silver, gold and platinum).
When it comes to making sure your family has health insurance, there are a number of choices. Medical bills can be one of the leading contributors to bankruptcy, and women may need more specialized care due to our unique needs. A few final reminders: speak up! Asking your employer for coverage is always an option and there are a lot of resources to help defray healthcare costs for lower income women.
Your best bet is to ask and keep asking, until you find enough coverage for your family.