Understanding affordable
health coverage.

Your premium is what you pay every month to keep your health plan active, whether you use it or not. You might pay it yourself or have it taken out of your paycheck if you get coverage through work. The premium only buys access to the plan: you may still owe a deductible, copays and coinsurance when you get care. That's why the plan with the lowest premium isn't always the plan with the lowest overall cost. For a Marketplace plan, your premium also depends on your income, because tax credits can lower it. See real premiums for your ZIP code.

Usually, yes. The self-employed health insurance deduction lets you subtract premiums for yourself, your spouse and your dependents from your income on your federal return (it's an adjustment to income on Schedule 1 of Form 1040, so you don't have to itemize). Two rules to remember: you can only deduct premiums for the months you weren't eligible for an employer-sponsored plan through your own job or your spouse's, and you can't deduct more than your business earned that year. If you left a job in May and started your business in June, for example, you'd deduct June through December. Confirm the details with your tax professional.

HMO (health maintenance organization): you pick a primary care physician who coordinates your care, and you need a referral to see a specialist. Care outside the network isn't covered except in a true emergency. Networks are usually local. PPO (preferred provider organization): no primary care physician or referrals required. In-network care costs you the least, but out-of-network care is still partly covered, and the network often reaches across state lines. EPO (exclusive provider organization): a hybrid. Like a PPO, no referrals; like an HMO, nothing is covered outside the network. EPOs usually cost less than a PPO and a little more than an HMO. POS (point of service): the other hybrid. Like an HMO you need referrals from your primary care physician, but like a PPO you can go out of network at a higher cost.

A preferred provider organization is a health plan built around a network of doctors and hospitals that have agreed to lower rates. You don't need a referral from your primary care doctor to see a specialist, and PPO plans usually cover part of the cost of care outside the network too. That flexibility is why many of my self-employed clients and families prefer a PPO, and why private plans with PPO networks are often worth comparing against the Marketplace.

Your deductible is what you pay out of pocket for covered care each year before the plan starts sharing the cost. Some services, like an annual checkup or preventive care, are often covered before you meet it. Deductibles vary a lot by plan, from a few hundred dollars to several thousand for an individual, and roughly double that for a family. Plans with higher deductibles usually have lower premiums and vice versa. Example: with a $1,000 deductible and a $5,000 surgery, you pay the first $1,000 and the plan covers all or most of the remaining $4,000. Even after you meet the deductible, some services may still have a copay or coinsurance.

A copay (copayment) is a flat fee you pay for a specific service, like $30 for a doctor visit or $10 for a generic prescription. It's set by the insurer and doesn't change with what the doctor charges. Not every service has one: preventive care usually doesn't, specialists often cost more than your primary care doctor, and brand-name drugs cost more than generics. As a rule, plans with lower monthly premiums have higher copays, and plans with higher premiums have lower copays.

The Affordable Care Act, passed in 2010, was designed to make health insurance easier and more affordable to get than to go without. It created the Marketplace where you can buy plans, with tax credits based on income; made it illegal to deny coverage or charge more for a pre-existing condition; set a minimum level of coverage every plan must include; funded Medicaid expansion in the states that chose it; and added rules for what larger employers must offer. The federal tax penalty for going uninsured was reduced to $0 starting in 2019, though a few states have their own. My plain-English ACA guide has the rest.

In most cases, emergency care is covered wherever you are. If you live in Utah and break a leg in New York, a good health plan will cover the emergency room visit. The caveats: follow-up and non-emergency care away from home depends on your plan's network, so HMO and EPO plans may leave you paying full price outside your area, while PPO plans usually cover some out-of-network care. If you travel a lot or spend part of the year in another state, tell me and I'll look for a plan with a network that travels with you.

No. My help is free to you. Licensed agents are paid by the insurance company you choose, and the plan costs the same whether you use me or not.

No. I'm an independent agent. I compare plans from multiple insurers, on and off the Marketplace, and explain the trade-offs so you can choose.

No. My plan shopper shows live Marketplace prices with just your ZIP code, ages and an income estimate. You only share contact details if you want my help.

Usually, yes. The key is making sure your doctors and hospital are in the plan's network. I check that before you enroll.

Each plan has its own drug list. Send me your medications and I'll check how each plan covers them and what you'd pay.

ACA Open Enrollment starts every November 1. Outside it, you need a qualifying life event such as marriage, a new baby, a move or losing other coverage. Most private plans can start on the first of any month.

I'm based in Heber City, Utah and licensed in about 30 states. Enter your ZIP code in the plan shopper or book a call and I'll confirm.

Shop plans and enroll yourself online, or book a free call and I'll walk you through it start to finish.