Navigating Health Insurance for Students Over 26

Turning 26 marks a significant milestone, especially concerning health insurance. This is because, until your 26th birthday, you can remain covered under your parent's health insurance plan, regardless of your marital status, student status, or living situation. However, once you reach this age, it's time to explore your own health coverage options. This article aims to guide students over 26 through the various health insurance choices available to them.

Understanding the Basics

Before diving into the specifics, it's essential to grasp some fundamental concepts related to health insurance. Terms like "premiums," "deductibles," and "out-of-network providers" can seem complex, especially if your academic pursuits lie outside the realm of health education.

Preliminary Healthcare Considerations for Grad Students

Before enrolling in a healthcare plan, it's important to consider your current situation. Factors like your age, healthcare needs, school requirements, and available insurance options will inform you what healthcare plans are available to you.

According to the Council of Graduate Schools, today’s average grad student age is 33 years old. This statistic is important because grad students are only eligible to be covered under their parent’s healthcare plan until they turn 26.

When exactly you age out of your parents’ plan also differs, depending on the type of plan they have. If they have marketplace insurance (health insurance independent of their job), you can stay on their plan until Dec. However, if your parents have health insurance through their job, you age out the month you turn 26. When this happens, you enter a special enrollment period, during which you have 60 days of additional coverage and 60 days after that to sign up for a new plan.

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Health Insurance Options for Students Over 26

Several avenues exist for students over 26 to obtain health insurance coverage. Let's explore these options in detail:

1. Job-Based Coverage

If you are employed, enrolling in your job's health insurance plan is a viable option. Employers typically contribute to your premium, the amount paid to an insurer for coverage. Be sure to research if your graduate program automatically enrolls students in a health insurance plan or has an open enrollment period so you know when to submit your employer-based insurance. If your employer-based health insurance covers less than your school requires, you may have to buy supplemental insurance.

2. Health Insurance Marketplace Plans

The federal government operates the Health Insurance Marketplace, with some states running their own versions. These Marketplaces offer a range of plans, and during the application process, you'll discover if you qualify for Medicaid or the Children's Health Insurance Program (CHIP). These plans are independent of your employer, so you will have to pay the premium on your own.

The United States government regulates an open marketplace for citizens who don’t get health insurance through their employer. Under current law, these plans must offer a minimum level of coverage - and they must disclose what is offered before you enroll. If interested in this option, make sure you enroll during the set registration period (typically Nov. 15 through Jan. 15).

3. Student Health Plans

If you're under 30 and enrolled in school, you may be eligible for a student health plan. Contact your school's health services department to explore this option.

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When required, most schools offer a graduate student health insurance option. Some schools have an automatic enrollment policy, where all graduate students are enrolled in a plan, and students must submit a waiver to avoid the student insurance fee. The University of Iowa, on the other hand, offers students an open enrollment period instead of automatically enrolling them into a health insurance plan. No matter what type of enrollment a school utilizes, students usually need insurance, either through the school or an independent plan that meets the institution’s standards.

4. Medicaid Plans

As the single largest healthcare provider in the country, Medicaid offers health insurance for over 72.5 million individuals. If you’re a low-income individual, you may be eligible for Medicaid, though the exact requirements vary by state. In all 50 states, pregnant women, children, low-income families, and those who receive Supplemental Security Income (SSI) are eligible for Medicaid. Beyond that, covered groups vary across state lines.

5. Parents’ plans

Many individuals in this age group can remain on their parents' health insurance plan.

6. Individual and family health plans

Available on the Healthcare Marketplace or directly through insurers, there are a variety of plans that fit specific needs and budgets.

Important Dates and Deadlines

Understanding key dates is crucial for a smooth transition in health coverage:

If you are on your parent’s employer-based plan: Coverage typically lasts through the month of your 26th birthday. For example, if your birthday is on May 1, you’ll have coverage through May 31.
If you are on your parent’s Marketplace plan: Coverage ends Dec. 31 during the year you turn 26, regardless of your birthdate.
Open Enrollment: If you want to enroll in your own Marketplace plan, you can do so during open enrollment (Nov. 1 - Jan. 15).

When you’re covered through your parents’ plan, you have 60 days to enroll in a new plan. If they receive insurance through the Marketplace, you’re covered on their plan until the end of the year and may choose a new plan in the open enrollment period (Nov. 1 through Jan. 15). To learn if you can switch over to your university’s graduate student health insurance plan, reach out to your individual institution.

Choosing the Best Health Insurance Plan

When choosing the best healthcare plan, there is more to consider than your age, your school’s requirements, and the provider. Each healthcare insurer may offer multiple plans you qualify for. To add to this, there are a variety of different factors to consider - so how do you choose?

Step 1: Understand Your Healthcare Plan Options

After you’ve considered your age, your university’s requirements, and different provider types, it’s time to understand the essential components of each plan you’re considering.

Enrollment Period

The first detail to note is the enrollment period. For marketplace plans and many employers, the enrollment period is from Nov. 1 through Jan. 15. University-sponsored plans for graduate students sometimes have different enrollment periods. You’ll also want to pay attention to schools with automatic enrollment, such as Rice University.

Insurance Tier

Plans in the marketplace, as well as some other plans, are presented in four tiers: bronze, silver, gold, and platinum. Platinum has the highest premium, the set rate you pay each month, but the lowest out-of-pocket costs. Bronze has the lowest monthly premium, but the highest out-of-pocket costs and the least amount covered. At universities with Student Health Insurance Plans (SHIPs), there may only be one level, not many.

In-Network vs. Out-of-Network

government defines a network as the providers a specific insurance provider has a contract with to provide healthcare services to their insurees. For example, if your healthcare plan is through United Healthcare Student, you’d want to go to medical providers in United Healthcare’s network. When you go to an out-of-network provider, some or all costs won’t be covered. A point of service (POS) plan charges you less when you use medical providers within your network. A health maintenance organization (HMO) limits coverage to healthcare providers contracted by an HMO.

Step 2: Compare Healthcare Plan Coverage

Once you’ve looked at the different healthcare plans and understand the terms of each, it’s time to compare your options.

Primary Care Provider (PCP)

Your primary care provider is a doctor (sometimes a nurse practitioner or physician’s assistant) who is your go-to person for all healthcare concerns. They treat common conditions, offer preventative care, and refer out to specialists as needed. Some insurance providers have a list you must choose from, while others let you choose anyone within your network. Make sure to research what each plan you’re considering allows, including if your current PCP is covered.

Medication

Before looking at plans, write down all medications you currently use. When reading the terms of each health insurance plan you’re considering, note if all your required medications are covered. It’s also important to determine if a provider covers generic or brand name medication. Since the FDA has determined generic drugs have the same active ingredient and effect as name-brand ones, health insurance providers are not required to cover both by law.

Pre-Existing Conditions

Pre-existing conditions, like pregnancy and asthma, are conditions that increase how much you might spend on healthcare. In the United States, no healthcare provider is allowed to deny coverage or charge more because of a pre-existing condition. The only exception to this is grandfathered plans, which means the plan was in existence before March 23, 2010, and hasn’t changed since; check with your university or employer to confirm if they have a grandfathered health insurance plan. Marketplace plans, however, are never grandfathered.

Specialist Visits (Therapy, Dermatologist, etc.)

Each health insurance plan has a different copayment amount and referral process for visiting a specialist. For a specialist visit to be covered, you usually must be referred by your PCP, though this might not be the case with all plans. In your plan’s terms, there should also be a stated amount you have to “copay” to see a specialist. For example, if you are referred to a back specialist, your plan could have a $40 copay for going to a specialist in your network and a $70 copay if you choose an out-of-network specialist.

Urgent Care/Emergencies

Unlike seeing a specialist, an insurance provider can’t charge you more if you see an out-of-network provider in an emergency. That means your copays and deductible payments will be the same no matter where you’re treated, and these appointments don’t need to be pre-approved by your provider.

Step 3: Consider the Costs

No matter what health insurance plan you choose, you most likely will have to pay some money yourself.

Coinsurance

The Department of Health & Human Services defines coinsurance as the amount you pay after your deductible has been met. The number is usually stated in your plan as a percentage. For example, let’s say your coinsurance amount is 20%. If you’ve already met your deductible and you receive a medical bill for $200, your coinsurance would be $40. Your insurance provider would pay the rest.

Copayments

A copayment is a defined amount you pay for any medical service after you’ve met your deductible. Unlike a coinsurance, this number is set, not a percentage. The amount should be defined by medical service type. For example, one plan might charge a copayment (or copay) of $50 for a physical therapy appointment, while another could charge $30.

Deductibles

A deductible is the amount you have to pay before your insurance provider pays for healthcare services. For example, if your plan has a deductible of $1,000, you have to pay that amount yourself before a health insurance company covers any medical bills. There are often certain charges, such as a checkup with your PCP, that are covered before you meet your deductible. The exact terms and exceptions should be defined in a plan’s terms and conditions.

Out-of-Pocket Limit/Maximum

The maximum, often called the out-of-pocket limit, is the highest amount you might have to spend on health insurance costs in a single year. This covers your deductible, out-of-network costs, coinsurance, and copays. In 2024, the out-of-pocket limit on Marketplace plans is $9,450 for an individual and $18,900 for couples. For other plans, this amount could be lower.

Premiums

The premium is the amount you’re responsible for each month or year. For example, the University of Iowa has a $325 monthly premium for its student health insurance plan. If a student wants to cover their partner or children, that amount will increase.

Additional Considerations

The NAIC’s Health Insurance Shopping Tool: This tool can help determine which plan is right for you.
Marketplace Guidance: The Marketplace also has guidance on choosing a plan.
Beware of Non-Insurance Products: Some products aren’t health insurance and aren’t required to protect consumers in the same way as insurance. Health care sharing ministries (HCSMs), discount plans, or risk-sharing plans are not insurance products and are not governed by consumer protection laws.
State-Based System: The National Association of Insurance Commissioners (NAIC) provides expertise, data, and analysis for insurance commissioners to effectively regulate the industry and protect consumers.

Health Insurance for Online Students

Health insurance gets even more confusing for online students, considering some colleges, like the University of Southern Alabama, don’t require it for online students. Fortunately, it is possible to understand your university’s healthcare requirements without taking an entire class on it.

Am I required to have health insurance while enrolled in online college?

While it isn’t a federal or state law, almost all universities require health insurance for graduate students who attend school full time. At some schools, like the University of Nevada, Las Vegas, this only applies to those who are enrolled in 9 credit hours or more per semester. Even if health insurance isn’t a requirement by your university or if you’re a part-time student, you should be aware that there is a tax penalty in certain states for residents who don’t have health insurance. Not all states have this penalty, and there is no federal penalty.

When Insurance Isn’t Needed as an Online Student

At some universities, fully online students are not required to provide proof of insurance or eligible for graduate student health insurance.

Frequently Asked Questions

What happens if I can't afford health insurance? If you can’t afford health insurance, you may be eligible through Medicaid. While it’s important to check Medicaid’s eligibility requirements in your state, it’s generally available to those on Supplemental Security Income (SSI). Each state also has a certain percentage below the poverty line to qualify. If your income level is too high for Medicaid but paying for insurance is difficult, you may be eligible for a lower-cost plan through the Marketplace.
How does health insurance work for international students? If a university requires graduate students to have health insurance, that same policy applies to international students. That means international students in the United States will need to get a healthcare plan, often through their university.
How do I opt out of graduate student insurance? If you want to opt out of your university’s health insurance, you typically have to submit a waiver. The exact information you must submit and when your waiver is due depends on the university. For example, at the University of Maryland, the waiver is due between June 15 and Sept 30.

The Importance of Health Insurance

The benefits of young adults having health insurance is worth it. Even if you live a healthy lifestyle, having insurance gives you access to regular care to help maintain your wellness. It also offers a safety net in case of an unexpected health emergency.

Additional Resources

The NAIC’s Health Insurance Shopping Tool: Can help determine which plan is right for you.
Marketplace Guidance: The Marketplace also has guidance on choosing a plan.
Choosing a Health Insurance Plan: This guide from Washington University in St.
Graduate Students with Disabilities: If you’re a graduate student with a disability, you may have additional health and insurance concerns.
Health Insurance Glossary: As you review health insurance options, you might come across unfamiliar terms.
Medicaid Eligibility: If you’re a low-income student, your health insurance may be covered by Medicaid.
Seeing a Specialist: Still confused about how seeing a specialist works under your plan?
Subsidized Health Insurance: Some universities subsidize part of their graduate student’s healthcare costs.

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