Before you shop
What private coverage actually is — and when it is not the answer.
Medically underwritten plans are a different animal from marketplace coverage. For some people they cost less and cover more. For others they are simply the wrong product, and no amount of shopping around changes that. Here is how to work out which group you are in — including the parts that are not in our interest to tell you.
The difference
Two systems, two sets of rules.
Almost everything that matters comes down to one question: does your health history affect what you are offered and what you pay?
ACA marketplace
- Nobody can turn you down. Pre-existing conditions cannot raise your price or cost you the plan.
- Subsidies follow income. Premium tax credits can cut the cost dramatically depending on your household.
- Ten benefits are guaranteed. Maternity, mental health, prescriptions, and preventive care are required by law.
- You enroll on a schedule. Once a year, unless something in your life qualifies you for a special window.
Private / underwritten
- Your history is reviewed. Carriers can decline you, exclude a condition, or price you differently based on it.
- No subsidies at all. You pay the full premium no matter what you earn.
- Benefits are whatever the contract says. There is no federal floor, so what is covered has to be read rather than assumed.
- You can apply any month. No open enrollment window, though approval is still up to the carrier.
The part we would rather you knew: if you qualify for a meaningful marketplace subsidy, or you have a significant pre-existing condition, or you are planning a pregnancy — an ACA plan is very likely the better option for you. A broker worth talking to will say that out loud instead of steering you somewhere else.
Who it fits
Where private coverage tends to work.
These are patterns rather than promises. Your own numbers depend on your health, your state, and which carriers write business there.
Self-employed
Freelancers and contractors
Once your income puts you past the subsidy cutoff, you are paying full price either way — so the comparison becomes plan against plan, and private options are worth pricing. Health premiums may also be deductible when you work for yourself; your accountant can tell you how that applies.
Business owners
Owner-operators and small LLCs
Coverage that belongs to you rather than to a group plan follows you through hiring, layoffs, and slow quarters. For very small teams, group and individual policies often price differently than owners expect, so it is worth running both before deciding.
Families
Households paying unsubsidized rates
Families above the subsidy line sometimes find that a healthy household underwrites well. This one swings hard on every member's history, which is why the estimate is a starting point rather than an answer.
Before you decide
Six questions worth asking any broker.
Us included. If someone gets vague on any of these, that itself is your answer.
Is this an ACA-compliant major medical plan?
Short-term, fixed-indemnity, and health-sharing-ministry products are not the same thing as major medical, and the difference becomes enormous the day you file a large claim.
Would I qualify for a subsidy instead?
Ask it directly. If the answer is yes and the number is substantial, the marketplace is probably your better deal and you deserve to hear that plainly.
What is excluded or capped?
Maternity, mental health, prescriptions, and any annual or lifetime limits. Get it from the plan documents in writing, not from a conversation you half remember.
Are my doctors actually in network?
Check with the practice directly as well as the carrier directory. Directories go stale, and the practice always knows sooner than the insurer does.
What happens at renewal?
Ask how the rate moves year to year, and whether a claim or a new diagnosis can change your terms when the policy comes up again.
How do you get paid on this?
Every broker earns something. The answer should come easily and specifically. Ours is on the homepage, because you should not have to ask.
See your range before you talk to anyone
Five questions, about a minute, no contact details required.