Answers to Your Biggest Health Insurance Questions

An HMO requires you to choose a primary care doctor and get referrals to see specialists. You're limited to a specific network of providers. A PPO gives you more flexibility — you can see any doctor or specialist without a referral, and you're covered both in-network and out-of-network (though in-network costs less). For people who travel, see multiple specialists, or want freedom of choice, a PPO is usually the better fit.

Your deductible is the amount you pay out of pocket before your insurance starts sharing costs with you. If your deductible is $2,000, you pay the first $2,000 of medical bills each year yourself. After that, your insurance kicks in and starts covering a portion of your costs.

Your premium is what you pay every month just to have insurance — whether you use it or not. Your deductible is what you pay when you actually use it, before insurance starts covering costs. Think of the premium as your monthly membership fee, and the deductible as your starting tab when something happens.

A copay is a fixed dollar amount you pay for a service — like $30 every time you see your doctor, regardless of the total bill. Coinsurance is a percentage split — like 80/20, meaning insurance covers 80% and you cover 20% of the remaining bill after your deductible. Copays are predictable; coinsurance depends on the total cost of care.

Your out-of-pocket maximum is the most you'll ever pay in a single year for covered medical expenses. Once you hit that number, your insurance covers 100% of the rest. This is one of the most important numbers on any plan — it's your financial safety net in a worst-case scenario like a surgery or serious illness.

A PPO is usually the better choice if you have existing doctors you want to keep, you travel frequently, you see specialists regularly, or you want the flexibility to get care without referral hoops. If cost is the only priority and you're generally healthy, an HMO can save money — but most of my clients find the flexibility of a PPO is worth it.

It depends on the plan and the doctor. With a PPO on a major network like UnitedHealthcare, most physicians nationwide are covered. Before enrolling any client, I always verify that their specific providers are in-network so there are no surprises after the fact.

In-network providers have a contract with your insurance company and agreed to discounted rates — so your costs are lower. Out-of-network providers haven't agreed to those rates, so you may pay significantly more, or the visit may not be covered at all depending on your plan. A PPO covers both; an HMO typically only covers in-network.

At minimum, a plan that protects you from catastrophic costs — a high out-of-pocket maximum means one bad year could wipe you out financially. Beyond that, it depends on how often you use care, whether you have a family, and your budget. I help people find the right balance between monthly cost and coverage depth.

High-deductible plans have lower monthly premiums but you pay more upfront when you need care — good for generally healthy people who rarely use medical services. Low-deductible plans cost more per month but kick in sooner — better for people with ongoing prescriptions, regular visits, or a family with kids. I run the numbers with each client to figure out which actually costs less over a full year.

Yes — and this is one of the most overlooked options. There are medically underwritten private PPO plans available year-round that aren't tied to open enrollment. They often have lower premiums than ACA marketplace plans for healthy individuals and include strong nationwide PPO networks. These plans aren't right for everyone, but for healthy self-employed people they're worth a serious look.

You have a few options: COBRA (continues your old employer coverage but is usually expensive), ACA marketplace plans (income-based, available within 60 days of losing coverage as a qualifying life event), or private individual plans available year-round. Leaving a job is a qualifying life event, so you're not stuck waiting for open enrollment. I help people evaluate all three options side by side.

Absolutely. Many small business owners get better coverage and lower costs through individual plans than group plans — especially with just one or two employees. Individual PPO plans can cover the owner and their family, and premiums may be tax-deductible as a business expense.

Adding a spouse or dependents to an employer group plan can be surprisingly expensive — sometimes $500–$800 more per month. In many cases, a private individual plan for the spouse is significantly cheaper with comparable or better coverage. This is one of the most common situations I help families navigate.

Yes — 1099 contractors have access to the same individual and family health plans as anyone else. You just don't have an employer subsidizing the premium. Many 1099 contractors also qualify for self-employed health insurance deductions that can reduce the net cost significantly.

Premiums vary based on your age, where you live, whether the plan is medically underwritten, the size of the network, the deductible level, and whether the plan is ACA-compliant or private. Two people the same age can pay very different amounts depending on their health history and the type of plan they qualify for.

In most cases, yes. Self-employed individuals can deduct 100% of health insurance premiums for themselves, a spouse, and dependents as an adjustment to income — not just as an itemized deduction. This is a significant tax benefit that makes private health insurance more affordable than many people realize. Always verify with your CPA for your specific situation.

If you miss ACA open enrollment without a qualifying life event, you can't enroll in a marketplace plan until the next open enrollment period. However, private medically underwritten plans are available year-round and don't follow open enrollment rules — a solid option for healthy individuals who missed the window.

Yes. Private individual health plans — medically underwritten and not sold on the ACA marketplace — are available 365 days a year. If you're healthy and looking for coverage outside of open enrollment, these plans are often worth exploring. I can walk you through what you'd qualify for in about 15 minutes.

The most important ones: Is my doctor in-network? What is the out-of-pocket maximum? What does the plan cover for prescriptions? Is there a copay for office visits or do I pay until I hit my deductible? What network does the plan use? Can I see specialists without a referral? I go through all of these with every client before we enroll.

Choosing based on the lowest monthly premium without looking at the out-of-pocket maximum. A $200/month plan with a $15,000 out-of-pocket maximum can be financially devastating if you actually need care. The real cost of a plan is the premium plus your realistic expected out-of-pocket costs — not just the monthly number. I help people do that math before they commit.