How Health Benefits Work

Individual Coverage on GetCoveredNJ

Look at individual coverage if:

  • You can't get Medicaid
  • You can’t get Medicare, and
  • You can’t get employer-sponsored coverage.

Is It Right for You?

With individual coverage, an individual or family pays a monthly premium and the plan agrees to pay some of the costs of approved medical services when needed, including preventive care, lab tests, surgery, or prescription drugs. If you have low to moderate income, the government may help you pay for your monthly premium and get a plan with lower copayments.

Answer the questions on this page to see if it might make sense for you to get individual health coverage. If it does, sign up using GetCoveredNJ, the easiest place to comparison shop for an individual plan and the only place where you might be able to get help from the government to pay for your private insurance.

Do You Have Any Better Options?

If you can get Medicaid, Medicare, or employer-sponsored coverage, you don’t qualify for government help to pay for an individual plan. That means they are usually a better choice than getting an individual plan, because they cost less.

Can You Get Medicaid?

Medicaid is a government health program for people with low income. It’s a great program that usually has no monthly premium and copayments for services that are usually much lower than copayments required by individual plans. Also, Medicaid may cover some services that an individual plan doesn't cover.

If you can’t get Medicaid, individual coverage might be a good option for you.

You may qualify for Medicaid if you are in one of these situations:

Can You Get Medicare?

Medicare is a government health program for seniors (65 years old or older) and people with disabilities. To get Medicare coverage, you or a family member must have worked for a certain number of years and met other eligibility rules.

If you get Medicare, you cannot get government help to pay for an individual health plan. You can still buy an individual plan through GetCoveredNJ, but you have to pay the entire premium yourself. Note: If you get Medicare and want more coverage than it offers, look into Medicare Advantage or Medicare supplement policies. GetCoveredNJ does not offer these.

If you can’t get Medicare, individual coverage might be a good option for you.

Can You Get Employer-Sponsored Coverage?

Many employers offer private health coverage as a job benefit for employees, their children until they turn 26, and their spouses. If your employer offers you health coverage that would cost you less than 9.12% of your household’s income and that coverage meets bronze-level standards, you won't qualify for government help paying for an individual plan. If you can get employer-sponsored coverage, but sign up for an individual plan anyway, you will have to pay the full premium.

Note: Before 2023, the spouse or children of an employee would not qualify for subsidies on GetCoveredNJ if the employer offered coverage that was affordable for the employee's policy alone, even if the cost to add the rest of the family wasn't affordable. This was called the "family glitch." This changed starting in 2023. Learn more about affordability rules for family members and how it affects eligibility for tax credits on GetCoveredNJ.

If you can’t get employer-sponsored coverage, individual coverage might be a good option for you.

When an Individual Plan Is Your Best Option

You should get an individual plan through GetCoveredNJ if you cannot get health coverage from:

  • Your job
  • Your spouse’s job
  • Your parent’s job
  • Medicaid, or
  • Medicare.

The government may make your individual plan more affordable if you cannot get health coverage from any of the above options:

  • You may get a tax subsidy to help pay your monthly premium.
  • You may also qualify for a plan with lower expenses, such as smaller copayments, if your family’s income is at or below 250% of the Federal Poverty Guidelines (FPG) ($36,450 for an individual; $75,000 for a family of four).

Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

When GetCoveredNJ looks at your income, they count most of your earned and unearned income. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect whether you get help paying for individual coverage.

Try GetCoveredNJ's shop and compare Tool.

Health Coverage Income Limits for Your Family
Choosing a plan

Carefully compare your options when you get an individual plan. All plans must cover the Essential Health Benefits. However, the amount you have to pay for your premium and other fees, such as copayments, co-insurance, and deductible depends on your exact plan.

There are four levels of plan:

  1. Platinum plans have the highest monthly premiums and the lowest fees when you get medical care.
  2. Gold plans have slightly lower premiums and slightly higher fees when you get medical care.
  3. Silver plans have lower premiums. The fees for medical services depend on your family’s income. If your income is at or below 250% of FPG, the fees may be as low as a gold or platinum plan.
  4. Bronze plans have the lowest monthly premiums and the highest fees when you get medical care.

You may see these plans listed with percentage ratings (60%, 70%, 73%, 80%, 87%, or 90%). The higher the percentage rating, the lower the fees you have to pay when you get medical care.

The bottom line: If your income is at or below 250% of FPG, sign up for a silver plan. Otherwise, think about how much you typically spend on medical care to decide which metal plan is best.

How to Sign Up

GetCoveredNJ is a one-stop shop where you can compare plans and figure out which is right for you. And it is the only place where you can get government help to pay for your individual plan.

Start out by comparing your options with GetCoveredNJ's shop and compare Tool, so that you can make an informed decision when you are ready. If you find GetCoveredNJ confusing or think there is a mistake, get help by calling GetCoveredNJ at 1-833-677-1010 or get local help.

Open Enrollment

Open enrollment for individual plans has ended for this year. People in certain situations can still sign up for a health plan under special enrollment rules.

Usually, you can only sign up for an insurance plan through GetCoveredNJ during a specific time called open enrollment:

  • To get an individual plan that covers you during 2025, you must sign up between November 1, 2024 and January 31, 2025.
  • If you do not sign up during that time, you are not usually allowed to sign up for an individual plan through GetCoveredNJ until another year has passed.

Special Enrollment

You can sign up for an individual plan through GetCoveredNJ even though it is not the usual open enrollment period if:

  • Your household income is at or below 150% of FPG
  • You lose other health coverage you had
  • Your health coverage is not meeting its obligations
  • Your income changes and you gain or lose eligibility for government help paying for your coverage
  • You become a legal resident of the U.S.
  • You move
  • There was a mistake in your enrollment, or
  • In other life-changing circumstances, such as having a child or getting married.

Note: American Indians do not have these restrictions on enrollment.

Learn more