Coverage Basics
HMO plans require you to choose a primary care physician and get referrals to see specialists, usually at a lower cost. PPO plans offer more flexibility to see any provider without referrals, including out-of-network, but typically cost more.
Your premium is the amount you pay monthly to keep your insurance active, regardless of whether you use it. Your deductible is the amount you must pay out-of-pocket for covered services before insurance starts sharing costs.
It's still recommended — a serious accident or unexpected diagnosis can result in tens of thousands of dollars in medical debt without coverage. Many young, healthy people opt for lower-premium Bronze or catastrophic plans as a cost-effective safety net.
Enrollment & Eligibility
Open enrollment for ACA marketplace plans typically runs November 1 to January 15 each year. Outside that window, you generally need a qualifying life event (job loss, marriage, having a baby, moving) to enroll through a special enrollment period.
Under the Affordable Care Act, ACA marketplace and employer plans cannot deny coverage or charge more due to pre-existing conditions. Short-term health plans are an exception and can exclude pre-existing conditions.
Cost & Claims
Costs vary widely by plan tier, age, location, and subsidy eligibility — ACA marketplace premiums range from $0 (with full subsidy) to $500+/month for a Bronze plan without subsidies, with Gold and Platinum plans costing more.
It's the most you'll pay in a plan year for covered services before your insurance pays 100% of remaining costs. It includes your deductible and coinsurance, but typically not your monthly premiums.