Health Insurance FAQs

You pay a monthly premium to keep coverage active. When you need care, you and the plan share costs: you pay toward your deductible first, then copays or coinsurance, and the plan caps your total yearly exposure at the out-of-pocket maximum.

The fixed amount you pay every month to keep your coverage active — you pay it whether or not you use any care that month.

The amount you pay out of pocket before your plan starts sharing costs. Preventive care is usually covered before the deductible, while services like imaging or surgery count toward it.

A flat fee you pay for a specific service — for example $30 for a doctor visit or $15 for a generic prescription — with the plan covering the rest.

The percentage of costs you pay after meeting your deductible. On an 80/20 plan, the carrier pays 80% of a covered bill and you pay 20% until you reach your out-of-pocket maximum.

The most you can be required to pay for covered services in a plan year. Once you hit it, the plan pays 100% of covered costs for the rest of the year.

Premiums vary widely with age, location, household size, plan type, and whether you qualify for premium tax credits. Comparing several carriers side by side — which a broker does for free — is the only reliable way to find your real cost.

Preventive care, doctor visits, emergency services, hospitalization, prescriptions, lab work, and more — ACA-compliant plans must cover ten categories of essential health benefits. The details (networks, drug formularies, cost-sharing) are where plans differ.

Adult routine eye exams generally aren't covered by medical plans — that's what standalone vision insurance is for. Children's vision screening is an essential health benefit, and medical eye problems (like injuries or disease) fall under your health plan.

Generally no — routine adult dental work is excluded from health plans. Standalone dental plans are affordable and can be purchased year-round; children's dental is often available as part of marketplace coverage.

Marketplace open enrollment typically runs November 1 through January 15. Outside that window, a qualifying life event opens a special enrollment period — and some private and short-term plans can be purchased year-round.

A change that opens a special enrollment period: losing other coverage, moving, getting married or divorced, having or adopting a child, or turning 26 and aging off a parent's plan, among others.

An HMO requires you to stay in-network and get referrals, in exchange for lower premiums. A PPO covers out-of-network care and needs no referrals, at a higher premium. An EPO sits in between: no referrals, but no out-of-network coverage except emergencies.

Temporary coverage that bridges gaps — between jobs, waiting for benefits, after a life change. It can start as soon as the next day and costs less than comprehensive coverage, but excludes pre-existing conditions and isn't a long-term substitute.

Compare four things side by side: monthly premium, deductible and out-of-pocket maximum, whether your doctors and hospitals are in-network, and how your prescriptions are covered. The best plan is the one with the lowest total yearly cost that keeps your doctors.