Definitions and FAQ's

Some terms maybe confusing to understand for most people so I will try to explain the terms in a less “insurance” form.


This is the amount of money that you will pay first before the insurance company will start to help with your cost in most cases. With “copay” plans you will pay a certain amount to see the doctor per visit, but this copay will not reduce the deductible in your policy.


Like I mentioned before, a copay is the amount you will pay to see a doctor or urgent care facility or emergency room, but this amount does not reduce your deductible, and even if your deductible is paid you will still have to pay the copay amount to see your doctor. Generally copay plans are more costly per month in premium.


Coinsurance is the amount you pay in conjunction with the insurance company. Most plans work where you end up paying the same amount if your cost were to exceed the max out of pocket cost. Coinsurance can be viewed like this: Deductible is $1000. Then you pay the coinsurance of $5000 at a 80/20 or 70/30 or 50/50 split. So if your total out of pocket is $6000 before the insurance pays 100% of medical cost. $1000.00 deductible is all on you. $5000 you pay at a rate of 20% of the bill until you have paid $5000. Your total out of your pocket is $6000 whether you have a $1000 deductible or a $2000 deductible and a max out of pocket of $6000. Then your coinsurance would be $4000. Either way you still pay $6000.00 if your situation cost $6000 or more.

Max Out of Pocket Cost

Max out of pocket cost is the total amount you will pay per year if your medical expenses exceed that amount. Most insurance plans are a set amount of max out of pocket no matter what policy you get. Whether it is a “Bronze” “Silver” or “Gold” plan MOST of the time your deductible is different but your max out of pocket is the same. Example: Silver plan may have a deductible of $4000 with a max out of pocket of $6600 meaning you pay a max of 6600 but the $4000 is your cost first. A gold plan may have a $2000 deductible with a max out of pocket cost of $6600. Supplemental insurance can help with these high out of pocket costs.

Frequently Asked Questions

#1. Why can't I buy insurance throughout the whole year?
You can with a SEP (special enrollment period) birth of a child, marriage or divorce, or loss of insurance from work. If you do not fall in this category you may be able to purchase a short term policy to protect you until open enrollment.

#2. Does short term policies meet the government requirements?
No, because short term policies are underwritten they do not cover pre-existing conditions. Therefore they do not meet government requirements and may be subject to a tax.

#3. What if I lose my job mid-year do and I can't afford insurance?
You may qualify for exemption through the website.

#4. Do I have to go to to enroll if I'm getting a subsidy?
No. If you qualify for a subsidy I will do that for you at no charge to you. I have the ability to check for your subsidy and apply and even help you purchase your health care coverage.

#5. What if I am self-employed and I do not want to go through
That is fine, and I work with many businesses that do not want to go through the government website. I help them and many times their employees as well, again at no cost for my services.

#6. What if I have a plan from before Obamacare started but I want to make a change?
You may have what is called a grandfathered plan. Many times plans will change in cost or the insurance company may do away with that plan, and you may have to get an ACA plan. However, if your plan is still in operation, but you want to make a change, it is my understanding that you cannot make any changes to your grandfathered plans without switching to an ACA plan but first talk to your insurance company that issued your plan.

#7. I am 25 and in collage for my masters, I work part time and I can't afford the coverage the school offers; what can I do? I don't make a lot of money.
You are able to stay on your parents insurance until you turn 26 years of age. Or you may qualify for a catastrophic plan, because you're under 30 years of age. Or you may want to look into a short term plan.

#8. I'm a 45 year old man with no kids and in great health; why do I have to pay for dental for a child, and maternity? I can't get pregnant!
I do not make the laws, I just help people get insurance. If you want the laws changed then the people need to let their law makers know.

Rodney Horne
(602) ­686-­8923