Your Insurance Questions
Answered In Plain English

HMO (Health Maintenance Organization): You choose a primary care physician who coordinates your care. Specialist visits require a referral. You must stay in-network (except emergencies). Lower premiums and out-of-pocket costs.

PPO (Preferred Provider Organization): See any doctor — no referral needed, in-network or out. More flexibility, but higher premiums and out-of-pocket costs for out-of-network care.

Bottom line: If you have specific doctors you want to keep and they are out-of-network for HMOs, a PPO may be worth the extra premium. Our agents will check your preferred doctors before recommending a plan.

You can enroll during a Special Enrollment Period (SEP) if you experience a qualifying life event:

• Lost job-based coverage (you have 60 days)
• Got married, divorced, or had a baby/adoption
• Moved to a new state or coverage area
• Gained citizenship or legal status
• Income changed enough to affect subsidy eligibility

Medicaid and CHIP have open enrollment year-round — if your income is low, you may qualify right now. Call us and we will check immediately.

Average unsubsidized premium: $500–$600/month for an individual. But with ACA premium tax credits, millions of Americans pay $0–$100/month.

Your actual cost depends on: age · ZIP code · household income · plan tier (Bronze/Silver/Gold/Platinum) · number of people covered.

Quick rule: If your income is under ~$58,000/year as a single person, there is a good chance you qualify for subsidies. Get a free quote and we will show you exactly what you will pay.

The out-of-pocket maximum is your financial safety net — the most you will ever pay for covered services in a plan year. Once you hit it, your insurance pays 100% of covered costs for the rest of the year.

For 2025 ACA marketplace plans, the caps are:
• Individual: $9,450
• Family: $18,900

This includes your deductible, copays, and coinsurance — but NOT your monthly premium or out-of-network charges on some plans.

ACA premium tax credits are available if your household income is between 100% and 400% of the Federal Poverty Level (and under recent expansions, even above 400%). For a single person in 2025:

• 100% FPL = ~$14,580/year
• 400% FPL = ~$58,320/year

Even if your income is above $58K, you may qualify if your benchmark plan premium exceeds 8.5% of your income. Our agents check your exact eligibility for free — most people are surprised how much they can save.

An HSA is a triple-tax-advantaged account paired with a High Deductible Health Plan (HDHP):

1. Tax-deductible contributions — reduce your taxable income
2. Tax-free growth — invest the balance like a 401(k)
3. Tax-free withdrawals for qualified medical expenses

2025 contribution limits: $4,300 (individual) | $8,550 (family). Unused funds roll over every year — there is no "use it or lose it." Many financial advisors call the HSA the best savings vehicle available.

A common starting point is 10–12× your annual income. But the right amount for you depends on:

• Outstanding debts (mortgage, student loans, car)
• Number and ages of dependents
• Future education costs for children
• Spouse's income and earning potential
• Final expense and burial costs (~$10,000–$15,000)

Example: A 35-year-old earning $70K/year with a mortgage and two young kids likely needs $700K–$1M in coverage. A 20-year term policy can cost less than $40/month at that age.

Term Life: Coverage for a set period (10/15/20/30 years). Pays death benefit only if you die during that term. Most affordable option — ideal for income replacement during your working years.

Whole Life: Permanent coverage + builds cash value you can borrow against. Premiums are fixed but much higher than term (often 5–15× more expensive for same coverage).

Our recommendation for most families: Start with a large term policy to protect your income now, and consider whole life later for estate planning or guaranteed insurability. Our agents will show you side-by-side quotes.

Yes — most people with pre-existing conditions can still get covered. The key is working with an agent who knows which carriers are most favorable for specific conditions:

• Well-managed Type 2 diabetes: Can often get standard or near-standard rates
• Cancer in remission 5+ years: Many carriers will approve
• Serious heart history: Guaranteed issue or simplified issue policies available

Guaranteed issue policies (no medical questions) are available up to $25,000–$50,000. If you have been turned down before, call us — you likely have more options than you were told.

In most cases, no. Life insurance death benefits paid to a named beneficiary are generally income-tax-free under IRS Section 101(a). This is one of the most powerful financial advantages of life insurance.

Exceptions to know:
• Interest earned if you take a lump sum after delay may be taxable
• If the estate is the beneficiary, it may be subject to estate tax on large estates
• "Transfer for value" rule if a policy was sold or transferred

For the vast majority of families, the full death benefit goes directly to loved ones — tax-free.

Most dental plans follow the 100-80-50 rule:

• 100% covered — Preventive: Cleanings (2/year), X-rays, exams, sealants
• 80% covered — Basic: Fillings, extractions, root canals, periodontal treatment
• 50% covered — Major: Crowns, bridges, dentures, implants (some plans)

Annual benefit maximums typically range from $1,000 to $2,000. Orthodontics usually requires a separate rider (teen braces/Invisalign). Some premium plans include implant coverage.

For most people — yes. Here is the math:

• Basic dental plan: ~$20–$30/month ($240–$360/year)
• 2 cleanings without insurance: ~$300–$400
• 1 crown without insurance: $1,000–$1,500
• 1 root canal without insurance: $700–$1,500

If you get your two routine cleanings per year, dental insurance pays for itself. If you need any restorative work, the savings can be in the thousands. People who skip dental insurance often end up paying far more when small problems become big ones.

Many individual dental plans impose a waiting period before covering major services:

• Preventive care: Usually covered immediately (day 1)
• Basic services (fillings): Often 3–6 month wait
• Major services (crowns, root canals): Often 6–12 month wait

Good news: Employer group plans and some individual plans waive waiting periods entirely. If you need work done soon, tell our agents — we will specifically look for no-waiting-period plans available in your area.

Basic plans typically do not cover implants — they are considered a cosmetic/elective procedure by most insurers. However:

• Premium individual plans may cover 50% of implant costs (up to the annual max)
• Some group employer plans include implant coverage
• Standalone "implant insurance" and dental discount plans exist that can reduce implant costs significantly

A single implant costs $3,000–$5,000 without any coverage. If implants are in your future, let us find a plan that covers them — it can save you thousands.

Standard ACA health plans do NOT cover routine vision for adults. They only cover eye care tied to a medical condition (like diabetic retinopathy or glaucoma treatment).

To get coverage for:
✓ Annual eye exams
✓ Glasses frames and lenses
✓ Contact lenses

…you need a separate vision insurance plan. The good news: vision plans are very affordable, usually $10–$20/month, and they typically pay for themselves in the first visit.

A standard vision plan typically includes:

• 1 comprehensive eye exam/year — often fully covered after a small copay ($10–$20)
• Frame allowance: $100–$200 toward glasses frames
• Lens coverage: Single vision, bifocal, and progressive lenses covered or discounted
• Contact lens allowance: $100–$200 in lieu of glasses
• LASIK discount: 15%–20% off at participating providers

Major carriers: VSP, EyeMed, Humana Vision, Cigna Vision, Davis Vision.

LASIK is generally considered elective, so most plans do not pay the full cost. However, most vision insurance plans offer a LASIK discount benefit through network providers:

• Typical discount: 15%–20% off the retail price
• Some plans offer a flat rate (e.g., $1,800/eye instead of $2,500+)
• VSP and EyeMed both have LASIK discount programs

Average LASIK cost without any discount: $4,000–$5,000 for both eyes. With a vision plan discount, you can save $600–$1,000+. Ask about plans with strong LASIK benefits when you call us.

COBRA lets you keep your employer's health plan after leaving a job — but you pay 100% of the premium plus a 2% admin fee. The average cost is $600–$700/month for an individual and $1,700+/month for a family.

COBRA lasts up to 18 months (sometimes 36 months in certain situations).

Is it worth it? Rarely. Losing job-based coverage is a qualifying life event that opens a 60-day Special Enrollment Period. Marketplace plans — especially with ACA subsidies — are often far cheaper with comparable or better coverage. Call us before you elect COBRA.

Employer plans are usually the best deal because your employer pays 50%–80% of the premium. But not always — compare these factors:

• If your employer plan costs more than 9.02% of your household income for self-only coverage, you may qualify for marketplace subsidies instead
• Dependent coverage is often NOT subsidized by employers, making individual/family marketplace plans cheaper for kids
• Marketplace plans may have broader networks in your area

Our agents run side-by-side comparisons so you see exactly which option saves you more money.

Coverage timing by product type:

• Short-term health plans: As fast as next day
• ACA marketplace plans: 1st of the following month (or mid-month in some states during SEP)
• Term life insurance: 24–48 hours with instant-decision carriers
• Dental & vision: Typically 1st of the month after enrollment
• Medicaid: Can start same day if approved

Click here to speak with a live agent — we will find the fastest path to getting you covered.

Maybe — and this is one of the most important things to verify before enrolling. An out-of-network doctor visit can cost 2–5× more than in-network.

How we help: Before recommending any plan, our agents verify that your specific doctors, specialists, and preferred hospital are in-network. We pull the carrier's provider directory in real time and confirm before you commit.

PPO plans offer the most flexibility (you can see out-of-network providers at higher cost). If keeping your doctor is non-negotiable, we will prioritize PPOs or EPOs that include them.

You have more options than most people think:

1. Short-term health plans — Can start tomorrow. Cover major illnesses/accidents while you wait for the next enrollment period. Not ACA-compliant but far better than nothing.
2. Health sharing ministries — Faith-based or secular cost-sharing programs, lower monthly contributions
3. Medicaid / CHIP — Year-round enrollment if you qualify by income
4. Employer plan — If you just started a job, you have a new-hire enrollment window
5. Association health plans — Through a professional, alumni, or trade association

Call us — we will find you something today.