Shane Kaibney Private Coverage Consultant

Marketplace · Employer · Private

All of it sucks. The job is finding the one that sucks least.

Nobody wants to pay for health coverage, and no plan will make you happy about the withdrawal. So the question was never which plan is good. It's which set of trade-offs you can live with, and that answer is different for a healthy 34-year-old contractor than for a family of five with a kid in therapy.

Marketplace, employer and private each solve a different problem. There is no perfect plan to go and find, only trade-offs you understand well enough to choose between.

No pitch Nothing on this page is gated No numbers that go stale About a 3 minute read

01 · Start here or none of the rest lands

You are not buying doctor visits.

This is the most useful thing I can tell anybody and almost nobody hears it before they shop. Once you have it, half the plans on the market disqualify themselves.

01

If this were about doctor visits, you'd pay cash.

Add up a year of premiums against a handful of office visits paid straight out of pocket. For a healthy person in a normal year, the cash is almost always cheaper. If routine care were the whole problem, insurance would be a bad product.

You're buying the month that ruins people.

You don’t pay a premium so a $100 office visit gets covered. You pay it against the one accident or diagnosis, with nothing on your record to warn you, that turns a year into bills measured in hundreds of thousands. The appendix at 2am. The scan that finds something. That is the actual product.

So what you're buying is less financial risk.

A cheap premium that leaves you exposed in the month that matters hasn’t saved you anything. It has moved the bill somewhere you can’t see yet. The number that decides whether a bad year is expensive or ruinous is the out-of-pocket maximum, and it’s the one nobody quotes you. Nobody chooses which year it happens; how much of it lands on you is the part you do.

02 · This one is mine, and it's why I sell it the way I do

I thought I was almost too healthy to need it.

I was healthy. Boringly healthy. One physical a year, no diagnosis on any record, no medication. Like most healthy people looking at a premium, I thought I was paying for a product I wasn’t using.

Then part of my vision went, and it did not come back. Retinal detachment. No underlying condition, nothing that would have shown up on any form I’d ever filled in. Three surgeries, five procedures, more than twenty appointments, roughly $50,000 of billed care inside twelve months. I had coverage, which is the only reason this is a story rather than a balance I’d still be paying down.

3 surgeries
5 separate procedures
20+ appointments
$50,000 billed, inside one year
1 visit on my whole record, the year before

Those are my own bills for my own care, not a quote and not a statement about what any plan pays. I’m not telling you this to frighten you into buying something. I’m telling you because I was the healthy person who understood the argument and still didn’t quite believe it, and nobody gets to pick their year.

03 · The comparison almost nobody is actually making

Most people shop the wrong numbers.

Not because they’re careless. Because these four are the only things two plans print side by side in the same size type, so they’re the only things that look comparable at a glance.

Premium

What leaves your account whether you use the plan or not. Real, and the easiest number here to shop on to your own cost.

Deductible

What you pay before the plan starts sharing. It matters, and it is not the ceiling. People read it as one constantly.

Carrier name

Tells you nothing about the network you were sold. The same carrier files very different plans in one county.

Copays

Felt most often, moves the total least. A $20 office visit is not what a bad year is made of.

What actually decides whether a plan is good for you

Seven things, and a quote shows you none of them.

  • Your maximum financial exposure. The most it can make you pay in the worst year it was built for.
  • The network, and whether your doctors are taking it. Two questions, and the directory answers one.
  • Your prescriptions, by name, on that plan’s drug list. A bad tier can outweigh every other difference between two plans.
  • What’s excluded. An exclusion on the exact thing you were covering is the worst outcome in this business.
  • Underwriting. Whether your own health is allowed to work in your favor, against you, or neither.
  • Renewability. Whether the carrier can re-rate you for getting sick while you keep paying.
  • Your household. Income, dependents, an employer contribution, a state line. Any one of them can move the answer to a different market.

The quote is the beginning of the comparison. It isn't the comparison.

04 · Different households belong in different lanes

Three markets, built for three different problems.

Each of these is the best answer for somebody. None is the best answer for everybody, and I’ll say that about the two I don’t get paid the same on.

The Marketplace

Nobody can turn you down, and nobody can charge you more for being sick

No health questions. Pre-existing conditions covered from day one, mental health and maternity carried as ordinary medicine, and income-based subsidies routinely larger than the whole difference between markets.

Where the trade-off appearsA healthy household above the subsidy band. Full price for a pool built to absorb everybody’s worst case, often on a county-sized network.

Employer coverage

When somebody else funds it, it is extremely hard to beat

The premium usually comes out pre-tax, so the real cost is lower than the pay stub says and an outside quote isn’t comparing like with like. The contribution is real money, and it’s guaranteed issue, same as the exchange.

Where the trade-off appearsThe moment you add dependents. Plenty of employers fund you generously and your family thinly. The total grows, their share barely moves, and the difference lands on your paycheck.

Private coverage

The one market where being healthy is allowed to help you

Medically underwritten plans ask health questions, and that’s the entire difference. Clear them and you’re priced on your own risk rather than the pool’s, usually on a broader PPO-style network.

Where the trade-off appearsHealth matters and the carrier gets a say. Approval isn’t guaranteed, and benefits vary far more between products than on the exchange. “A private plan” tells you nothing until you read what that one covers.

There’s a fourth, and it isn’t mine to sell. Turning 65, long-term disability, or income under the state’s line puts Medicare or Medicaid ahead of all three above. I don’t write either one. I do have Medicare partners I trust, so leave me your details and I’ll make the introduction.

05 · The part that decides whether any of the rest is worth reading

Sometimes the right answer isn't mine.

and I'd rather tell you that on the first call

  • If your employer is paying most of your premium, I’ll almost certainly tell you to keep it. That’s the best deal on this page and I won’t pretend otherwise to win a case.
  • If you qualify for a strong Marketplace subsidy, take it. The credit is routinely larger than the whole difference between markets, and being healthy doesn’t earn that back.
  • If private coverage doesn’t fit your health, I won’t pretend it does. Somebody in active treatment is better served by the market that can’t refuse them, and that’s the answer, not the consolation prize.

The job is comparing what’s available to your household, not moving everybody into one product. A plan that’s $80 a month less and doesn’t cover the one thing you were most likely to need hasn’t saved you $960. It has sold you the feeling of being covered.

06 · The long version, in one document

Want the framework I actually use?

I took the whole process I go through when I compare coverage for a household and put it in one guide. It’s this page with nothing cut out of it.

Marketplace. Employer. Private.

What each does well, where each falls apart, and what I’d check before enrolling in any of them. Twelve chapters, and a checklist at the back you can run on a quote that didn’t come from me.

What's inside

  • Marketplace against employer against private, side by side
  • Where each market wins, and where it struggles
  • The financial number I look at before the deductible
  • How medical underwriting actually works
  • Why taking medication doesn't automatically mean you're uninsurable
  • The network mistake most people don't find until they need care
  • How to tell major medical from limited-benefit coverage
  • The seven household situations I see most often
  • My own checklist for reading a quote before you enroll

Free, five fields, and it's the same information I'd give you on the phone.

Rather skip the reading? Go straight to the comparison, or call (813) 833-2628. Nothing here binds coverage; your quote is personalized and confirmed by a licensed agent.