Frequently Asked Questions About Private Health Insurance
Below are answers to some of the most common questions we receive about private health insurance and private PPO plans.
Private Health Insurance
-
Private health insurance is health coverage that you purchase directly through an insurance company or with the help of a health insurance broker, rather than receiving coverage through an employer or the ACA Marketplace.
Private health insurance plans can offer different networks, deductibles, cost-sharing and plan designs. The private health insurance policies we recommend are ACA compliant and provide comprehensive, major medical coverage.
If you're self-employed, a freelancer, contractor, business owner, retiree, or anyone else who needs to purchase your own health insurance, we can help you compare your available options.
-
ACA Marketplace plans provide comprehensive health coverage and may qualify for premium tax credits or other savings based on your household income and circumstances. Plan availability and provider networks vary by state and by plan. Some Marketplace areas offer PPOs, while many only offer HMO or EPO plans.
Private health insurance can provide access to additional plan options, including private PPO plans with broader provider networks and out-of-network benefits.
One of the biggest advantages of a PPO is flexibility. You can go to in-network or out-of-network doctors and hospitals, although your costs may be higher when you go out of network.
If you're comparing private health insurance with an ACA Marketplace plan, we can help you look at both options and determine which may provide the best overall value for your situation.
-
Eligibility depends on the specific plan and your circumstances. While not everyone qualifies for every private health insurance plan, many people who purchase their own coverage may have private options available.
Typical members of a private health plan include self-employed individuals, freelancers, 1099 contractors, business owners, employees who do not have employer-sponsored coverage, families and people who need coverage before becoming eligible for Medicare.
If you're currently paying for your own health insurance, it's worth comparing your options. We can help you determine which private health insurance plans you may qualify for.
-
We help individuals, families and businesses compare private health insurance options, including private PPO health insurance plans with nationwide provider networks.
The plans we recommend provide comprehensive, major medical coverage designed to protect you from significant medical expenses, including hospitalization and other major healthcare claims.
Every plan is different, so we compare the benefits, network, deductible, coinsurance, copays and out-of-pocket maximum to help you find coverage that fits your needs and budget.
Enrollment & Eligibility
-
Some private health insurance options are available outside of the ACA Marketplace Open Enrollment period. However, enrollment rules and eligibility vary depending on the specific plan and your circumstances.
Unlike Marketplace plans, which follow an annual Open Enrollment period with Special Enrollment Periods for qualifying life events, certain private health insurance options have different rules allowing new enrollments year-round.
If you need coverage outside of Marketplace Open Enrollment, contact us. We can help determine whether a private health insurance option may be available to you.
PPO Health Insurance
-
A PPO, or Preferred Provider Organization, is a type of health insurance plan that can give you more flexibility when choosing doctors, specialists, hospitals and other healthcare providers.
One of the biggest advantages of a PPO is out-of-network coverage. If you receive care from a provider who is not in the plan's network, the plan may still provide benefits, although you will pay more than you would for in-network care.
This can be especially important during a hospital stay or other major medical event, when you may not have complete control over which doctors or specialists participate in your care.
PPO plans also allow you to see specialists without selecting a primary care physician or getting a referral.
For people who travel, live in multiple states, want access to a broader network of doctors and hospitals, or simply want more flexibility when choosing healthcare providers, a PPO can be an excellent option.
-
The main difference between PPO, HMO and EPO health insurance plans is the amount of flexibility you have when choosing healthcare providers.
HMO: HMO plans use a defined provider network and may require you to select a primary care physician and obtain referrals to see certain specialists. Out-of-network care is generally not covered except in certain circumstances, such as emergencies.
EPO: EPO plans allow you to see specialists without a referral, but typically require you to use providers within the plan's network excluding circumstances like emergencies.
PPO: PPO plans provide the most flexibility. You can typically use both in-network or out-of-network doctors and hospitals, although your costs may be higher when you go out of network. PPO plans do not require referrals to see specialists.
The right plan depends on your doctors, hospitals, location, budget and how much flexibility you want from your health insurance.
-
One of the main advantages of a PPO is that it can provide benefits for covered services received from out-of-network doctors and hospitals.
However, not every PPO provides the same level of out-of-network protection. Deductibles, coinsurance, provider networks and out-of-pocket maximums can vary significantly from one policy to another.
With some PPO plans, you may have an out-of-network deductible and out-of-pocket maximum. Once you reach the applicable out-of-pocket maximum for covered services, the plan then pays 100% of additional covered expenses for the remainder of the calendar year, subject to the policy's terms, limitations and exclusions.
If you are considering a PPO, we can help you understand exactly how the plan's in-network and out-of-network benefits work before you enroll.
Private Health Insurance Costs
-
The cost of private health insurance varies depending on factors such as age, location, plan design, deductible, network and, for certain plans, eligibility and medical underwriting.
Some private health insurance plans are medically underwritten, meaning your health history may be considered when determining eligibility and pricing. Other plans have different eligibility requirements.
If you don't qualify for an ACA Marketplace subsidy, a private health insurance plan may offer competitive pricing and a plan design that provides better value for your particular needs. However, private health insurance is not automatically less expensive than Marketplace coverage.
Your income, eligibility for subsidies, health needs and the plans available to you can all affect which option makes the most sense.
A quick phone call or email can give you an idea of what private health insurance may cost before you decide whether to apply.
We can help you compare your available options and find the coverage that provides the best balance of price and benefits.
Pre-Existing Conditions & Underwriting
-
It depends on the type of private health insurance plan.
Some private plans are medically underwritten, meaning your health history may be considered when determining eligibility. Other private health insurance options have different underwriting and eligibility requirements.
Underwritten plans can be more restrictive for people with certain medical conditions or prescription medications. Some private plans that are not medically underwritten may be available to people with pre-existing conditions, although the premiums, benefits and eligibility requirements can be higher.
If you have a pre-existing condition or take prescription medications, it's important to review the specific plan before applying.
We can help you understand which options may be available based on your individual circumstances.
-
Some private health insurance plans are medically underwritten. This means the application includes questions about your health history, medical conditions, treatment and prescription medications.
Depending on the specific plan, underwriting may consider factors such as certain chronic health conditions, recent medical treatment, prescription medications, tobacco use and other health information.
Underwriting can affect whether you are eligible for a particular plan and, depending on the policy, may also affect the premium.
This is different from ACA Marketplace coverage. Marketplace plans cannot deny you coverage because of a pre-existing condition.
For someone with significant health conditions, Marketplace coverage may be an important option to consider. For someone who is healthy and does not qualify for a Marketplace subsidy, a medically underwritten private plan may provide a competitive alternative.
We can help you compare the available options before you make a decision.
Prescription & Preventive Care
-
Prescription coverage depends on the specific health insurance plan.
The private health insurance policies we recommend include prescription benefits and are ACA compliant. However, the medications covered, formularies, copays, deductibles and other prescription costs can vary by plan.
If you take regular medications, we can help you review the prescription benefits before you enroll so you understand how your medications are covered.
-
The private health insurance plans that we recommend are ACA compliant and provide comprehensive, major medical coverage.
Many preventive services are required to be covered without cost-sharing when provided by an in-network provider, although specific coverage requirements and circumstances can vary.
Before enrolling, we can help you review the plan's benefits so you understand what preventive care and other services are covered.
Understanding Your Health Insurance Costs
-
A deductible is the amount you generally pay for covered healthcare services before your health insurance plan begins paying according to its cost-sharing rules.
For example, if your plan has a $2,500 deductible, you will be responsible for the first $2,500 of covered expenses that are subject to the deductible. After that, you may pay coinsurance or copays depending on the plan.
Some services may be covered before you meet your deductible.
-
Coinsurance is the percentage of the cost of a covered healthcare service that you pay after you have met the applicable deductible.
For example, if your plan has 20% coinsurance, you would pay 20% for a covered service and the insurance company would pay the remaining 80% until you reach the applicable out-of-pocket maximum. Once your out-of-pocket maximum is met, the insurance company pays 100% of covered expenses for the remaining calendar year.
Common coinsurance amounts include 20%, 30% and 40%, but the amount varies by plan.
-
An out-of-pocket limit, also called an out-of-pocket maximum, is the maximum amount you generally pay during a plan year for covered services that are subject to the plan's out-of-pocket limit.
Depending on the plan, deductibles, copayments and coinsurance may count toward the applicable out-of-pocket maximum.
Once you reach the out-of-pocket maximum, the plan generally pays 100% of covered benefits for the remainder of the plan year.
Your monthly premium and services that are not covered by the plan generally do not count toward the out-of-pocket maximum. Out-of-network costs can also be treated differently depending on the policy.
This is one of the most important numbers to understand when comparing health insurance plans because it helps show how much financial protection you have in the event of a major medical claim.
-
A copay, or copayment, is a fixed dollar amount that you pay for a covered healthcare service.
For example, a health insurance plan may have a $30 copay for a primary care visit or a $50 copay for a specialist visit.
Copays can vary depending on the type of service and the specific health insurance plan. Some plans apply copays before the deductible, while others may require you to meet the deductible first.
The plan's Summary of Benefits and Coverage will explain exactly how copays work under that policy.
Getting Help Choosing Health Insurance
-
Health insurance plans can be difficult to compare. Two plans can have similar monthly premiums but very different deductibles, provider networks, prescription benefits, coinsurance and out-of-pocket maximums.
As health insurance brokers, we help you compare multiple options and explain the differences.
We're not afraid to tell you if your current policy is stronger than the alternatives we find. Our goal is to help you find better coverage for the same or less money whenever possible—not simply to sell you a policy.
-
Yes. We specialize in helping individuals, families and businesses compare private health insurance options, including PPO plans with broad and nationwide provider networks.
We look at the things that matter most to you, including your doctors, hospitals, prescriptions, budget, deductible and preferred level of coverage.
We will then help you compare the available options so you can make an informed decision.
-
Getting started is simple.
Fill out the form to get a quote here or call us directly at (609) 577-0006. Tell us what type of health insurance coverage you're looking for.
We will ask a few questions about your situation and help you determine what options may be available.
We can then provide a personalized quote and explain the differences between the plans you are eligible to consider.
Get your free personalized quote today - There is no cost and no obligation to review your options with us.