Individual & Family Q&A

An individual plan is a health plan available for individuals and families who do not have group health coverage 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 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 coverage 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 coverage, you will be responsible for 100% of your health care costs.
We are 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. We do 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, we become a secondary payer to Medicare.

To be complete, you must send us:

  • 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 — Provided by SSM Health Plan — primary care physician may request a referral. Without an approved referral from us, you are liable for any charges. You may not choose a non-plan provider as your primary care provider.
We encourage 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.

We offer 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, we 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. We 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 we will make payments toward services. After the deductible is met, we 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 we 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 the subscriber's:

  • Legally married spouse 
  • Partner in a Civil Union; 
  • Married or unmarried biological child, stepchild, child of a partner in a Civil Union, adopted child, foster child, legal ward and any child placed for adoption (by court order, a licensed county agency, an Illinois child welfare agency, or a child welfare agency licensed by another State) through the end of the month in which the child turns 26 years of age. All placements and adoptions must follow Illinois placement and adoptions laws. Contact our Customer Care Center if you have any questions; 
  • Biological child, stepchild, child of a partner in a Civil Union, foster child, or adopted child who was called to active duty prior to reaching the age of 27 and is a full-time student. The child has up to 12 months after completing active duty to apply for full-time student status at an institution of higher education. If the child has been called to active duty more than once in four years since the first call to active duty, eligibility will be determined based on the child’s age at the time of the first call to active duty; 
  • Dependent's biological child until the Subscriber’s dependent reaches the age of 18. 

To add a qualified dependent to an existing plan, the policyholder must complete a new individual plan application.