Individual & Family Q&A

An individual plan is available for individuals and families who do not have group health insurance provided by any carrier though an employer. WellFirst Health — provided by SSM Health Plan — offers different individual plan designs with varying benefit and coverage levels to fit your family's healthcare and financial needs.
Open enrollment is the period of time during which individuals may enroll in a qualified health plan. The next open enrollment period runs from Nov. 1 until Dec. 15.

Qualified individuals may enroll in a health plan during the special enrollment period, if you experience a qualifying life event.
You may only sign up for health insurance during the enrollment period or under special circumstances, such as losing your coverage because of a job layoff, etc. If you become ill and do not have insurance, you will be responsible for 100% of your health care costs.
WellFirst Health is contracted with independent agents and agencies who specialize in individual health plans. Agents can help you find the best plan for your current needs. If you need help finding an agent in your area, contact us. 

Yes, a number of our individual plans are designed to be compatible with HSAs.

If you choose an HSA-eligible plan design, you have the freedom to select where you would like to set up your financial HSA account. WellFirst Health does not contract with or recommend any HSA custodian. Contact a trusted bank or financial institution for more information about setting up an HSA.

As you become eligible for Medicare, you may continue your individual plan coverage. Please note when individual plan members become eligible for Medicare, WellFirst Health becomes secondary payer to Medicare.

To be complete, WellFirst Health must receive:

  • Fully completed application form.
  • Check for your first month's premium or complete the Authorization for Automatic Transfer of Funds page within the application form.
If you wish to continue seeing a non-plan provider for services you are unable to obtain within the network, your WellFirst Health primary care physician may request a referral. Without an approved referral from WellFirst Health, you are liable for any charges. You may not choose a non-plan provider as your primary care provider.
WellFirst Health encourages you to be proactive about your health. Preventive care such as routine physical exams, mammograms, well-baby care and more are covered. Immunizations are covered at 100% for all of our plans.

WellFirst Health offers the following premium payment methods:

  • Automated cash handling (ACH) – ACH is our automated bank withdrawal program. With ACH, the exact premium amount is automatically withdrawn from your bank account monthly.
  • Direct billing – If you choose direct billing, WellFirst Health will bill you monthly. You may prepay your monthly premium up to 12 months in advance.

Note: Premium checks must be from a personal checking account. WellFirst Health will accept business account checks under these following guidelines:

  • Subscriber is self-employed.
  • The business is not paying for more than two employees.
  • The billing address remains the subscriber's address.

Many factors determine your premium, such as:

  • Tobacco/non-tobacco use
  • Selection of deductible, coinsurance and benefit options
  • The age of you and your spouse (if applicable) on the policy effective date
  • Coverage option, for example: single, applicant/spouse, applicant and child(ren) or full family
  • Location of residence

You must first pay up to the amount of your deductible before WellFirst Health will make payments toward services. After the deductible is met, WellFirst Health will pay a percentage of the coinsurance until you have met the dollar amount listed in the annual out-of-pocket limit.

For health savings account plans, if you have family coverage, the family deductible must be satisfied before WellFirst Health will pay for covered services.

If you need emergency care, you should call 911 or proceed immediately to the nearest medical facility. Emergency care is covered anywhere in the world. If you are out of our service area and must use a non-plan provider, call the Customer Care Center as soon as reasonably possible.

If you need urgent care and are within our service area, you must use a plan physician, clinic or urgent care facility.

If you are outside our service area and cannot safely return to receive care from a plan provider, go to the nearest appropriate medical facility and notify the Customer Care Center as soon as possible. Follow-up care must be received from a plan provider.

Individual policies purchased before Jan. 1 of every calendar year offer 12 months of coverage. Depending on which calendar month your policy began, your benefits and deductible will start over 12 months later on your policy renewal date. (Example: If your Individual Plan coverage began on Aug. 1, your policy benefits and deductible will start over one year later on Aug. 1).

Policies purchased after Jan. 1 of each year are calendar year. Regardless of the month coverage begins, all benefits and deductibles will start over on Jan. 1 each year.

A qualified dependent may be:

  • a legally married spouse.
  • a biological child from birth, adopted child, child placed for adoption, or stepchild to the maximum dependent age limitation selected by your employer.
  • a legal ward residing with you in a parent-child relationship who is dependent on you for at least 50% of support and maintenance.
  • a grandchild, until the eligible parent dependent child reaches age 18.
To add a qualified dependent to an existing plan, the policyholder must complete a new individual plan application.