Your Path to Wellness, Your Power to Choose, Your Inner Peace.

What It Is:

The fixed amount you pay each month to keep your plan active, whether or not you use medical services.

How It Works:

Paid monthly to your insurance provider (or deducted from a subsidy if eligible)

The premium is not the cost of care—it’s the membership fee to stay covered.

What Affects It:

Factors like age, location, tobacco use, plan metal tier, and who is covered.

Marketplace subsidies (Premium Tax Credits) can significantly reduce your monthly cost.

Pro Tip:

Balance the premium with potential out-of-pocket costs. A lower premium usually means higher costs when you receive care.

Example:

$420/month premium with no subsidy → you pay $420.

If eligible for a $250 subsidy → you pay $170 per month.

What It Is:

The total amount you pay for covered services before your plan begins sharing costs through coinsurance.

How It Works:

Deductibles reset each plan year.

Many plans cover preventive care before the deductible (often $0).

Watch For:

Embedded family deductibles: each family member has their own cap in addition to the overall family cap.

Some plans have separate pharmacy vs. medical deductibles.

Pro Tip:

If you anticipate major procedures, choosing a lower deductible can save you money overall, even if the premium is higher.

Example:

$2,000 deductible → you pay the first $2,000 of covered expenses (after any copays) before coinsurance begins.

What It Is:

A predictable, flat dollar amount you pay for specific services—even before reaching your deductible (varies by plan).

Common Copays:

Primary care: $20–$50
Specialist: $40–$80
Urgent care: $60–$100
Prescription tiers: e.g., $10 / $35 / $75 / 30%

Pro Tip:
Telehealth visits often have lower copays than in-office appointments—review your plan’s perks.

Example:

$35 PCP copay → you pay $35 at the visit; your plan covers the rest (contracted rate).

What It Is:

The portion of costs shared between you and your plan after your deductible has been met.

Typical Splits:

80/20, 70/30, or 60/40 (the plan pays the first number).

Pro Tip:

Coinsurance is based on the negotiated rate, not the provider’s full price. Staying in-network can save you significantly.

Example:
80/20 coinsurance on a $1,200 allowable charge → you pay $240; your plan covers $960.

What it is:

The maximum you’ll spend in a year for covered, in-network care—including your deductible, copays, and coinsurance.

After you reach it:

Your plan covers 100% of eligible, in-network services for the rest of the plan year.

Pro tip:

Think of this as your financial safety ceiling. Always compare out-of-pocket maximums when choosing a plan—it defines your true worst-case cost.

Example:
If your out-of-pocket maximum is $8,700, once your total spending reaches that amount, you’ll pay $0 for covered, in-network services for the rest of the year.

What It Is:

A network of doctors, hospitals, and facilities that have agreed to provide services at discounted rates through your insurance plan.

Types:

HMO: In-network care only; usually requires a primary care referral.
PPO: Offers both in- and out-of-network care; no referrals needed.
EPO: In-network only, but typically no referral required.

Pro Tip:

Before any major procedure, double-check that all providers involved (surgeon, lab, anesthesiologist, etc.) are in-network to avoid surprise bills.

Example:

An in-network MRI might cost $600, while the same scan out-of-network could run $1,800—same service, triple the price.

What It Is:

Routine checkups and preventive services designed to maintain your health—often covered at no cost when you use in-network providers.

Examples:

Annual wellness exams and basic lab screenings
Vaccinations (flu, COVID-19, Tdap, etc.)
Recommended cancer screenings (mammogram, colonoscopy, etc.)

Pro Tip:
When booking, mention it’s a preventive visit—additional diagnostic tests may be billed separately.

What It Is:

A statement from your insurance company detailing what was billed, the approved amount, what your plan covered, and what portion (if any) you owe.

Why It Matters:

Helps identify possible billing errors.
Tracks your progress toward your deductible and out-of-pocket maximum.

Pro tip:

Always review your Explanation of Benefits (EOB) before paying a provider bill—charges often adjust once insurance processing is complete.

What It Is:

A federal tax credit that lowers your monthly premium when you enroll through the Marketplace and meet income and household size requirements.

How You Get It:

Applied monthly to reduce your premium, or claimed when filing taxes.
Report any income changes to avoid over- or under-paying.

Pro Tip:
Use a conservative income estimate and update it during the year to ensure your credits stay accurate.

What It Is::

A set annual period during which you can enroll in a plan, switch coverage, or add dependents for the upcoming year.

Missed It:

You typically need a Special Enrollment Period (SEP) to make changes outside this window.

Pro Tip:

Consider the total cost—premium plus expected medical expenses (prescriptions, specialist visits) and out-of-pocket maximum—rather than focusing on the premium alone.

What It Is::

A 60-day period that lets you enroll in or change health coverage due to certain life events.

Common Qualifying Events:

Marriage or divorce
Birth or adoption of a child
Permanent move to a new state or area
Loss of other qualifying coverage

What you’ll need:

Documentation proving the event (e.g., marriage certificate, proof of coverage loss, lease or utility bill for moves).

Pro Tip:

Submit your application as soon as possible—coverage start dates may depend on when you apply within the 60-day window.