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Individual & Family Health Insurance

Not all health coverage is the same thing.

This is a big part of what I do, and it is the area where people are most often sold something they did not understand. Let’s fix that.

There are two very different kinds of product sitting under the words “health insurance,” and they are not interchangeable.

One is comprehensive major medical — ACA-compliant coverage, the kind most people picture. The other is a family of private and supplemental products that pay in specific situations, on specific terms. Both can be useful. They are not substitutes for one another, and anyone who tells you otherwise is doing you harm.

My job on this page is to make the difference obvious before you are ever asked to choose.

What is it?

Health insurance is an agreement about who pays when you need care. What separates one product from another is the answer to four questions:

  1. What does it pay for?
  2. What does it not pay for?
  3. Does it cap what you could end up owing?
  4. Can you be turned down or charged more for your health history?

Hold those four questions in your head as you read the rest of this page. They are the ones that matter.

Please read this part, even if you skip the rest

Private supplemental and indemnity products are not the same thing as ACA comprehensive major medical insurance, and I will never present them as if they are.

A hospital indemnity plan, an accident plan or a scheduled-benefit plan can be genuinely useful — but it pays set amounts in set circumstances. It is not a replacement for comprehensive major medical coverage, and it does not do the same job. If anyone has offered you one as though it were, please let me look at it with you.

Who might it be for?

People come to me for health coverage at all sorts of moments:

  • You are self-employed, a contractor, or running a small business without a group plan.
  • You have left a job, or your employer coverage is ending.
  • You are covering a family and want to understand what you are actually buying.
  • You are under 65 and not yet eligible for Medicare.
  • You have a plan already and cannot tell whether it is any good.
  • You have been sold something and want a second opinion on what it really covers.

ACA / Marketplace major medical

Marketplace plans are ACA-compliant comprehensive major medical insurance. This is the comprehensive category.

Depending on your eligibility and your household circumstances, you may qualify for a premium tax credit that lowers what you pay each month. Whether you qualify, and by how much, depends on your situation — it is worth checking rather than assuming, in either direction.

Here are the terms you will meet, in plain English:

Premium
What you pay every month to keep the plan, whether or not you use it.
Deductible
What you pay yourself before the plan starts sharing most costs.
Copay
A fixed amount for a particular service — say, a set fee for a doctor visit.
Coinsurance
A percentage of the cost you keep paying after the deductible is met.
Maximum out-of-pocket
The ceiling. The most you would pay in a plan year for covered, in-network care. This is the number that protects you in a bad year.
Provider network
The doctors, hospitals and facilities the plan has agreements with. Going outside it usually costs much more, and sometimes is not covered at all.
Prescription coverage
Every plan has its own drug list and tiers. Check your own medications, not the general description.
Preventive care
ACA-compliant plans cover a defined set of preventive services in network without you paying toward the deductible.

The trap here is comparing plans on premium alone. A cheaper monthly premium with a higher deductible and a narrower network can cost you far more over a year — or far less, depending entirely on how much care you actually use. That is a conversation, not a calculation you should have to do alone.

Private health options

For people who want or need to explore alternatives, there are private products that work differently. Depending on the specific product, these may include:

  • Indemnity / scheduled-benefit coverage

    Pays set amounts for covered services, according to a published schedule — so much for a particular visit, procedure or day of care.

    Worth knowing: The schedule is the product. What is not on the schedule is not paid. These plans generally do not cap your total out-of-pocket exposure the way comprehensive major medical does.

  • Hospital indemnity

    Pays a set amount if you are admitted to hospital — often a fixed sum per day, or per admission — and the money is paid to you to use as you see fit.

    Worth knowing: Designed to sit alongside other coverage and help with the costs it leaves behind. It is not designed to be your only coverage.

  • Accident coverage

    Pays set benefits following a covered accidental injury — for example for emergency treatment, imaging, or a hospital stay that results from it.

    Worth knowing: Accident plans pay for accidents. Illness is a different matter entirely, and is generally not covered.

  • Specified-disease coverage

    Pays a benefit if you are diagnosed with one of the specific conditions the policy names, often as a lump sum.

    Worth knowing: The definitions in the policy do the work. Which conditions qualify, and at what stage, is written down precisely — and that wording is what you are buying.

  • Out-of-pocket protection

    Products designed to help with the deductibles, copays and coinsurance that a comprehensive plan leaves you to pay.

    Worth knowing: By definition this assumes you already have the underlying coverage. It is a companion, not a substitute.

  • Dental and vision

    Standalone plans for routine dental and eye care, which comprehensive medical plans often do not include for adults.

    Worth knowing: Covered in more detail on the Dental & Vision page — there is more variation here than people expect.

Before you buy any private product, you should be able to answer these

  • What does it pay, exactly? A set amount, a percentage, or the actual cost?
  • What does it not pay? Ask for the limitations and exclusions, and read them.
  • Is there a network? And are your doctors in it?
  • Is there underwriting? Can you be declined or rated because of your health history?
  • Are there waiting periods? Before certain benefits become available.
  • What happens in a very bad year? Is there a ceiling on what you could owe?

If you cannot get a straight answer to all six, that is your answer.

What should I know or consider?

The point of this page is not to push you toward one category. It is to make sure that when you choose, you know what you are choosing.

What I will do is go through it with you properly: what a product pays, what it does not pay, its limitations and exclusions, the network if there is one, and whether underwriting applies. Then you decide — with the full picture, not a sales pitch.

Sometimes we find you a better fit. Sometimes I tell you that what you already have is doing its job. Either way you will understand why.

To be confirmed by Tessa

Marketplace certification and licensing wording

Any required statements about Tessa’s Marketplace certification status, Federally-facilitated Marketplace registration, and the licensing and disclosure language her carriers require for these products need to be supplied by Tessa and added here in their exact approved wording before launch.

Take a moment

Check your understanding

Six questions. There are no wrong answers and nothing is scored — the point is to show you what a product is really telling you, and to let me know what to explain when we talk.

  1. 1 of 6 What does it pay, exactly?
  2. 2 of 6 What does it not pay?
  3. 3 of 6 Is there a network?
  4. 4 of 6 Is underwriting something you would want explained?
  5. 5 of 6 Are there waiting periods?
  6. 6 of 6 What happens in a very bad year?

That is the whole checklist. If a product cannot give you a straight answer to all six, that is your answer.

Book a time — and I will have your answers in front of me

Leave your name and email and your answers come with the booking, so we do not spend the first ten minutes covering ground you have already covered. Contact details only — please keep health details out of this, we will go through those properly when we talk.

Would rather not? Book without sending your answers.

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Send me what you have — or what you have been offered — and I'll tell you plainly what it covers and what it does not. No obligation, and no charge for the conversation.

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