Health Insurance
Which Type of Health Insurance Is Right for You?
There are several ways to get covered — here's what each one means.
Marketplace (ACA) Plans
Plans bought through Healthcare.gov or a broker like Cara. Available to individuals and families who don't have job-based coverage.
- 4 metal tiers: Bronze, Silver, Gold, Platinum
- Subsidies available based on income
- Open Enrollment: Nov 1 – Jan 15
Learn more about ACA plans →
Employer / Group Plans
Health insurance offered through your job. Your employer typically covers a portion of the premium, making it one of the most affordable options.
- Employer pays part of your premium
- Enrollment at hiring or annual open enrollment
- May include dental and vision
Medicaid
A free or very low-cost government program for people with low incomes. Run jointly by the federal government and each state.
- No or very low premiums
- Eligibility based on income & household size
- Coverage varies by state
Private / Off-Marketplace Plans
Plans purchased directly from an insurance company, outside of the ACA Marketplace. Offer more flexibility but no subsidy eligibility.
- Available year-round
- No income-based subsidies
- May offer more plan variety
Not sure which category you fall into? That's exactly what Cara is here for. A free consultation takes the guesswork out of it — she'll assess your situation and point you in the right direction.
Key Health Insurance Terms Explained
Tap any term to see a plain-English explanation.
ACA — Affordable Care Act+
The Affordable Care Act (ACA), also known as "Obamacare," is a federal law signed on March 23, 2010. It transformed how health insurance works in the U.S. by requiring plans to cover essential health benefits, banning insurers from denying coverage due to pre-existing conditions, allowing young adults to stay on a parent's plan until age 26, and creating the Health Insurance Marketplace where individuals can shop for and compare plans. It also introduced income-based subsidies (tax credits) to make coverage more affordable.
Example: Before the ACA, someone with diabetes could be denied coverage. Under the ACA, insurers must cover them at the same rates as anyone else.
Example: Before the ACA, someone with diabetes could be denied coverage. Under the ACA, insurers must cover them at the same rates as anyone else.
Premium+
Your premium is the monthly amount you pay to keep your health insurance active — whether you use it or not. Think of it like a subscription fee.
Example: You pay $320/month even in months you don't see a doctor.
Example: You pay $320/month even in months you don't see a doctor.
Deductible+
The amount you pay out-of-pocket for covered services before your insurance starts sharing costs. Once you hit your deductible, your plan starts paying its share.
Example: You have a $1,500 deductible. After you've spent $1,500 on care, your insurance kicks in.
Example: You have a $1,500 deductible. After you've spent $1,500 on care, your insurance kicks in.
Copay+
A fixed amount you pay for a specific service, like a doctor visit or prescription. Copays are usually due at the time of service.
Example: $30 copay every time you visit your primary care doctor.
Example: $30 copay every time you visit your primary care doctor.
Coinsurance+
After you meet your deductible, coinsurance is the percentage of costs you and your insurance split. Common splits are 80/20 (insurance pays 80%, you pay 20%).
Example: A $1,000 bill with 80/20 coinsurance means you owe $200.
Example: A $1,000 bill with 80/20 coinsurance means you owe $200.
Out-of-Pocket Maximum+
The most you'll ever have to pay in a plan year for covered services. Once you hit this limit, your insurance pays 100% of covered costs for the rest of the year.
Example: Your out-of-pocket max is $6,000. After that, everything else is covered.
Example: Your out-of-pocket max is $6,000. After that, everything else is covered.
Annual Maximum (Benefit Maximum)+
The total dollar amount your insurance plan will pay for covered services within a plan year. Once this cap is reached, you are responsible for all remaining costs for the rest of that year. Note: ACA-compliant plans do not have annual maximums for essential health benefits — this term is more common in dental, vision, and non-ACA plans.
Example: A dental plan with a $1,500 annual maximum will stop paying once it has covered $1,500 in dental work — any additional treatment that year is fully out of pocket.
Example: A dental plan with a $1,500 annual maximum will stop paying once it has covered $1,500 in dental work — any additional treatment that year is fully out of pocket.
Plan Networks — HMO, PPO, EPO & POS+
Your plan's network is the group of doctors, hospitals, and specialists that have agreed to your insurer's negotiated rates. Using in-network providers saves you money. Going out-of-network can cost significantly more — or may not be covered at all, depending on your plan type. The four main network structures are:
Example: With an HMO, seeing a cardiologist requires a referral from your PCP. With a PPO, you can book that appointment directly.
HMO — Health Maintenance Organization
Requires you to choose a primary care physician (PCP) who coordinates all your care. Referrals are needed to see specialists. Out-of-network care is generally not covered except in emergencies.
Lower cost, less flexibilityPPO — Preferred Provider Organization
The most flexible plan type. You can see any doctor or specialist — in or out of network — without a referral. In-network care costs less, but out-of-network is still partially covered.
Higher cost, most flexibilityEPO — Exclusive Provider Organization
Similar to a PPO in that you don't need referrals, but like an HMO in that you must stay within the network. Out-of-network care is not covered except in emergencies.
Mid-range cost, no out-of-networkPOS — Point of Service
A hybrid of HMO and PPO. You have a primary care physician and need referrals for specialists, but you can go out-of-network at a higher cost — giving you more options than a standard HMO.
Balanced flexibility and costPrior Authorization+
A requirement by your insurance plan that your doctor must get approval before providing certain services, medications, or procedures. Without prior authorization (also called pre-authorization or pre-approval), your plan may deny the claim and leave you with the full bill. Your doctor's office typically handles the request.
Example: Your doctor recommends an MRI. Before scheduling, the office submits a prior authorization request to your insurer. If denied, you can appeal the decision.
Example: Your doctor recommends an MRI. Before scheduling, the office submits a prior authorization request to your insurer. If denied, you can appeal the decision.
Subsidy / Tax Credit+
Financial assistance from the federal government that lowers your monthly premium. Eligibility is based on your income and household size. Many people qualify for more help than they realize.
Example: A family of 4 earning $60,000/year may qualify for hundreds of dollars in monthly savings.
Example: A family of 4 earning $60,000/year may qualify for hundreds of dollars in monthly savings.
Special Enrollment Period (SEP)+
A window of time outside of the regular Open Enrollment Period when you are allowed to sign up for or change a health insurance plan. Special Enrollment Periods are triggered by specific life changes. You typically have 60 days from the triggering event to enroll in a new plan.
Example: You lose your job-based coverage on June 1. You have until July 31 to enroll in a Marketplace plan without waiting for Open Enrollment.
Example: You lose your job-based coverage on June 1. You have until July 31 to enroll in a Marketplace plan without waiting for Open Enrollment.
Qualifying Life Event (QLE)+
A major change in your life that makes you eligible for a Special Enrollment Period. The most common qualifying life events include:
- Losing health coverage (job loss, aging off a parent's plan, loss of Medicaid)
- Getting married or divorced
- Having a baby, adopting a child, or placing a child for adoption
- Moving to a new ZIP code or county
- A change in income that affects your subsidy eligibility
- Gaining citizenship or lawful presence in the U.S.