Real answers to the questions people ask most.

You pay a premium to keep coverage active. When you receive covered care, the plan applies its negotiated or allowed amount and divides the cost using deductibles, copays and coinsurance. Coverage, authorization and network rules still apply.

There is no universal price. Premiums vary by ZIP code, age, household members, tobacco rules, plan, employer contribution and Marketplace assistance. Compare your location-specific after-subsidy premium plus expected medical costs.

The deductible is the amount you pay for applicable covered services before the plan begins sharing those costs. Preventive care and some copay-based benefits may be available before it is met. Family plans may have individual and family deductibles.

A copay is a fixed dollar amount, such as $40 for a visit. Coinsurance is a percentage of the plan's allowed cost, such as 20%. Either may apply before or after the deductible according to the policy.

It is the annual limit on qualifying covered in-network cost sharing. After reaching it, the plan generally pays 100% of covered in-network benefits for the rest of the plan year. Premiums, excluded care, out-of-network expenses and charges above allowed amounts generally do not count.

Medicaid or CHIP may be the lowest-cost comprehensive option for eligible households. Others may find employer coverage or a subsidized Marketplace plan most affordable. The lowest premium is not necessarily the lowest total cost.

Apply for all available savings, compare total annual cost, verify doctors and prescriptions, consider an adequate HMO or EPO network, match the metal level to expected care, explore HSA-compatible coverage and compare employer, Marketplace, Medicaid and CHIP options.

It is coverage purchased by a person or household rather than provided through an employer. It may be an ACA Marketplace plan, ACA-compliant off-Marketplace plan, medically underwritten private plan or limited-benefit product.

Private generally means the coverage is issued or administered by a private company rather than being a government program. It does not automatically mean PPO, nationwide, non-ACA or medically underwritten. The policy documents determine the product type.

A PPO contracts with providers to create a network and commonly allows specialist access without referrals and some out-of-network coverage. “Private PPO” is a broad sales phrase; verify the carrier, exact network, benefit structure, exclusions, underwriting and whether it is comprehensive major medical.

Neither is automatically better. A private PPO may offer network flexibility or different pricing. An ACA plan guarantees essential protections and may include subsidies. Compare medical history, prescriptions, maternity needs, provider access, benefits and maximum exposure.

An embedded deductible can begin benefits for one family member after that person meets an individual deductible. An aggregate deductible generally requires combined family spending to reach the family amount before deductible-based benefits begin. Review the Summary of Benefits and Coverage.

Consider it when employees request benefits, recruiting or retention is difficult, the workforce and budget are stable, carrier participation can be met, or the company approaches 50 full-time-equivalent employees. Employers averaging at least 50 FTEs in the prior year may have federal employer-coverage responsibilities.

Sometimes. The carrier must allow the arrangement and the network must serve every employee location. A national PPO may work; a local network may not. Employers should map employee ZIP codes and consider a national carrier, multiple options or an HRA strategy when one network cannot serve everyone.

An employer can generally discontinue coverage prospectively, but not necessarily instantly. Carrier contracts, plan documents, employee notice duties, payroll elections, COBRA or state continuation, premium obligations and replacement effective dates must be handled correctly.