Common questions,
plain answers.

These are the three main ways you share costs with your insurer.

Deductible — The amount you pay for covered services before your insurance starts paying. If your deductible is $1,500, you pay the first $1,500 of covered care each year yourself. (Preventive care like annual physicals is typically free even before you hit your deductible.)

Copay — A fixed dollar amount you pay for a specific service, regardless of your deductible. For example, a $30 PCP copay means you pay $30 every time you see your primary care doctor, even if you haven't hit your deductible yet.

Out-of-pocket maximum (OOP max) — The most you'll ever pay in a year. Once your deductible + coinsurance + copays reach this cap, your insurance covers 100% of covered in-network services for the rest of the year. This is your biggest protection against catastrophic bills. Federal law caps ACA out-of-pocket maximums (in 2026, it's $9,200 for individuals).

Metal tiers describe how costs are split between you and your insurer on average, called the "actuarial value."

The key insight: Lower metal tiers aren't automatically "worse." If you're young, healthy, and rarely use care, Bronze may cost you less overall. If you have chronic conditions or predictable high usage, Gold or Platinum often wins. Our scoring model simulates your actual costs to show you which tier is right for *your* situation.

The Advance Premium Tax Credit (APTC) — sometimes just called a "subsidy" — is financial help from the federal government that reduces your monthly premium on a Marketplace (ACA) plan.

Who qualifies? Generally, you need to:

- Enroll through the Health Insurance Marketplace (healthcare.gov or your state exchange)

- Have household income between 100% and 400% of the Federal Poverty Level (FPL). For 2026, that's roughly $15,060–$60,240 for a single person. The American Rescue Plan removed the income cap temporarily, and legislation has continued this — check healthcare.gov for the latest.

- Not have access to affordable employer-sponsored coverage or government coverage (Medicaid/Medicare)

How does it work? The credit is calculated based on the cost of the "benchmark" Silver plan in your area. You can choose to apply it to *any* metal tier — applying it to a Bronze plan can result in $0 or near-$0 monthly premiums for eligible households.

You can use our premium estimator tool to get a real-time APTC estimate based on your income and location.

This is about how you access care — specifically, which doctors and hospitals your plan will pay for.

HMO (Health Maintenance Organization)

- You must choose a Primary Care Physician (PCP) who manages your care

- You need a referral from your PCP to see a specialist

- Out-of-network care is generally not covered (except emergencies)

- Usually lower premiums and lower deductibles

- Best for: people who don't mind coordination, have a trusted PCP, and stay in-network

PPO (Preferred Provider Organization)

- No PCP requirement — you can see any specialist directly

- Out-of-network care is covered (at a higher cost-share)

- More flexibility to see any provider in or out of network

- Usually higher premiums

- Best for: people who value flexibility, travel frequently, or have specialists they want to keep

EPO (Exclusive Provider Organization) is a hybrid: PPO-like flexibility (no referrals needed) but HMO-like network restrictions (no out-of-network coverage).

Our scoring model factors in your network type when calculating predictability and risk scores.

There are two main windows when you can sign up for or switch plans:

Open Enrollment Period (OEP)

This is the primary annual window. For ACA Marketplace plans, it typically runs from November 1 to January 15 (dates vary slightly by state). Changes take effect January 1 (or February 1 if you enroll in January).

For employer plans, your company sets its own open enrollment window — usually in the fall.

Special Enrollment Period (SEP)

Outside of open enrollment, you can still enroll or make changes if you experience a qualifying life event, including:

- Losing existing health coverage (job loss, aging off a parent's plan, loss of Medicaid)

- Getting married or divorced

- Having a baby or adopting a child

- Moving to a new coverage area

- Gaining citizenship or lawful presence

You typically have 60 days from the qualifying event to enroll.

Medicare has its own enrollment windows: Initial Enrollment Period (around your 65th birthday), Annual Enrollment Period (Oct 15 – Dec 7), and Special Enrollment Periods.

Pro tip: Add open enrollment to your calendar now. Missing the window means waiting a full year unless you have a qualifying life event.