Shane Kaibney Private Coverage Consultant

The long version · free, in full

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.

This is all of it: every market, what each one is best at, where each one falls apart, and what to check before you sign. Nothing is held back for the phone call. If you read this and decide you don't need me, that's fine with me.

No pitch No email gate No numbers that go stale About a 14 minute read

What's on this page

01 What you're buying 02 The year it happened to me 03 The ACA, both sides 04 Private, and what's in it 05 Work plans and the family 06 Networks and acceptance 07 What health questions ask 08 The door that shuts 09 Which one of these is you 10 What isn't insurance 11 The one rule I'd keep 12 What to look out for 13 Why this is free

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 and compare it to 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 diagnosis or accident, 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. The pregnancy that ends in a NICU stay. That is the actual product.

And a diagnosis doesn't bill you once.

One event can leave you with a condition for good: the specialist every quarter, the drug every month, the scan every year. The spike is frightening. The new floor underneath it is what changes your life. Your ordinary year now costs what a bad year used to.

So the premium, alone, tells you almost nothing.

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 ruins you is the out-of-pocket maximum, and it's the one nobody quotes you. Routine benefits still matter. They're just not what you're buying.

In one line: you're buying less financial risk.

Nobody gets to choose which year it happens, which month, or what the diagnosis turns out to be. How much of it lands on you is the one part you do choose, and you choose it before anything has happened.

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.

The section above is the argument. This is what it looked like when it happened to the person writing the page.

I was healthy. Boringly healthy. A physical and nothing else, no diagnosis on any record, no medication. Like most healthy people looking at a premium, I thought I was paying a lot of money for a product I wasn't using.

Then part of my vision went, and it did not come back. Retinal detachment. No underlying condition, no cause anybody could point at, nothing that would have shown up on any form I'd ever filled in. There was only a treatment, and it started immediately.

Three surgeries. Five separate procedures. More than twenty appointments. Roughly $50,000 of billed care inside twelve months, starting from a year in which my entire medical history was one physical.

I had coverage, which is the only reason this is a story rather than a balance I'd still be paying down. And the part I think about most isn't the surgeries. It's that I had nearly talked myself out of coverage, for the reason most healthy people do: nothing had ever happened.

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, which depends on the policy. 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 · Credit where it's due, and where it isn't

The ACA is great at some things, and a poor fit for others.

I don't get paid the same on every market and I'll say this anyway: for a lot of people the Marketplace is the right answer. Its strengths have a cost, though. A pool that accepts everybody's worst case has to charge for it somewhere. If the pool is subsidizing you, take the deal. If you're subsidizing the pool, know that.

What it's great at

Guaranteed acceptance matters most, and it isn't close.

  • Nobody can turn you down. There are no health questions, so there's no decline for a diagnosis, a medication or a history.
  • Nobody can charge you more for being sick. Your price is your income and your age. The person on chemo and the person who runs marathons pay the same rate in the same county.
  • Pre-existing conditions are covered on day one. No waiting period, and no exclusion rider on the exact thing you need covered.
  • Mental health and substance use treatment. Therapy, psychiatry and rehab sit alongside medical care rather than in a stingy annex with a visit cap. If somebody in the house is in treatment, this alone can decide it.
  • Maternity as standard. Not a rider you had to buy twelve months before you got pregnant.
  • Preventive care at no cost to you. The physical, the standard screenings, the bloodwork: no copay, no deductible first.
  • Income-based subsidies, and they can be large. Large enough that for a lot of households nothing else on the market gets close.

Where the math turns against you

None of this makes the ACA bad. It makes it a poor fit for specific people.

  • You earn above the subsidy band. You pay full price for a plan built to absorb everyone's risk, often with a narrower network than you'd get elsewhere.
  • You're healthy. It is the only market where your own risk profile is legally not allowed to work in your favor.
  • Networks are often narrow. HMO-style, in-county, referral-gated. Chapter 06 is how to check yours.
  • Guessing your income wrong has a bill attached. Subsidies are paid on an estimate and reconciled at tax time. Earn more than you estimated and you pay some of it back, which hits commission, seasonal and self-employed income hardest.
  • It's an annual re-do. Plans, networks and pricing are rebuilt every year, so "set it and forget it" isn't on the menu.

Subsidy rules, including the enhanced credits, are set by law and have been changed and extended more than once. Whether they apply to you depends on your income, family size and plan year. That's a conversation with real numbers, not something a web page should assert.

04 · The lane most people have never had explained

Private coverage: you get priced on you.

Medically underwritten plans ask health questions. That is the entire difference, and it cuts both ways: it's why a healthy household can pay noticeably less for a broader network, and why this market can say no. Private is a different tool for a different health profile, not automatically a better one.

Strict approval

Full underwriting

You answer a real health questionnaire and the carrier decides. Clear it and you're priced on your own risk rather than the pool's, which is where the lower cost comes from. The coverage is customizable, built around your household rather than picked from four metal tiers somebody else designed.

What you get for it
Lower monthly cost for a healthy household, usually a broader PPO-style network, and a structure built around how your family uses care.
What it costs you
The carrier gets a say, and the answer is not automatically yes. It's also not the coin flip people imagine (chapter 07). The exclusions are the part to read slowly, and I read them with you before anybody signs.
Easier approval

When the health profile isn't a fit

A no on the strict lane isn't the end of the private market. Some private options have far easier approval, and two things about them surprise people: they can start in days rather than waiting for January 1, and for some households they come in under what the exchange would charge. The trade is usually a higher deductible or a different structure.

Where it fits
A history that rules out full underwriting, or a household that needs coverage in force soon and still wants private pricing and network breadth. Whether it fits you is a conversation, not a form.
What to watch
Structures differ far more here than on the exchange, so "private plan" tells you nothing on its own. What it covers, caps and excludes is the whole comparison.

What else is usually in the box.

Private plans are often sold as packages, and what sits alongside the major medical is frequently what a healthy family actually uses in an ordinary year, because a healthy family isn't hitting a deductible.

Usually included

Accident coverage

Pays a set amount when an injury happens, on top of what the health plan does with the bill. It's the benefit I see claimed most.

Usually included

Critical illness

A cash lump sum on a named diagnosis, cancer and cardiac events being the common ones. It pays the mortgage while somebody isn't working.

Usually included

Telemedicine

A doctor by phone or video, usually same day and at no visit cost. Families with small children use it constantly.

Usually included

Hospital and surgical benefits

Set payments per admission, per day or per procedure. They soften the part of a bad month you'd otherwise fund from savings.

Optional, and separate

Dental and vision

Almost always separate products you choose to add, not part of the health plan. Ask now rather than finding out at a front desk.

Varies a lot

Everything else

Prescription discounts, wellness benefits, disability riders. Packages differ most here, so read the benefit schedule, not the carrier's name.

Accident, critical illness and indemnity benefits are good value sitting on top of real major medical, and a serious problem sold as a substitute for it. Same products, opposite outcomes, and the difference is whether there's an out-of-pocket maximum underneath. Chapter 10 is about the second situation.

Availability, underwriting rules, what is bundled and what can be excluded all vary by state and by carrier. Nothing here is an offer of coverage or a statement about what you would be approved for or what any package would include.

05 · The one I most often tell people to keep

Employer coverage is hard to beat. Until you add the family.

If somebody else pays most of your premium, I'll tell you to stay put on the first call. But "I have it through work" is not the same as "I checked," and the check that matters most is what happens when you add dependents.

Why it's hard to beat

The advantage almost nobody counts is the first one.

  • Your premium usually comes out pre-tax. The real cost is lower than the number on the pay stub, so comparing it to a post-tax outside quote is comparing two different things.
  • The employer contribution is real money. A group where the company funds a serious share of your premium is the best deal on this page.
  • Guaranteed issue, same as the exchange. No health questions, no exclusions, covered from day one.

What depends on your employer

"Group coverage" describes the mechanism, not the quality.

  • Rates depend on the group. A small, older or high-claims group can be expensive. A large, well-subsidized one can be unbeatable.
  • The deductible can be brutal. Plenty of employer plans are high-deductible by design: low payroll deduction, large bill waiting behind it.
  • COBRA is the same plan without the employer's share. You pay all of it. Losing coverage also opens a special enrollment window, and that window closes.

The family cliff.

Covering four people costs more than covering one. What surprises people is how much more, and the reason is structural: a lot of employers fund your coverage generously and your dependents' thinly, or not at all. The total premium grows, the company's contribution barely moves, and everything in between lands on your paycheck.

Just you Employer funds most of it
You + spouse + two kids The growth lands on you
What the employer contributes What comes out of your paycheck

No numbers and no axis, on purpose. It shows what happens, not an amount: real figures differ between employers and move every plan year. Where an employer does put real money toward dependents, staying is usually right. So don't ask HR "what does the family plan cost." Ask "how much does the company contribute toward dependents." That answer decides it.

This is where an outside quote most often wins. Your own coverage may be worth keeping at work while the family is better covered somewhere else. Splitting the household across two markets is a completely normal outcome.

06 · The part that decides whether the plan works

A plan nobody will take isn't cheap. The cost just shows up later.

Plans get shopped on one visible number, so carriers compete on it, and the lever they pull is the network: fewer hospitals, fewer physicians, harder-negotiated rates. That's a real trade, not a scandal. But the plan that wins on premium is usually the one with the fewest doors, and the doors are the part almost nobody checks.

The carrier decides the network

This part you can see before you buy, if you look.

  • PPO, or HMO and EPO. On a PPO, going outside the network costs you more. On an HMO or EPO it's covered by nothing at all except a true emergency, and the whole bill is yours.
  • Often county-sized. Cross a county line for a specialist, spend part of the year elsewhere, or have a kid at college two states over, and the map matters.
  • Referral-gated. A primary care doctor has to send you to the specialist, which is fine until the referral is what stands between you and an appointment you need this month.
  • The hospital's name on the building tells you nothing. Contracts are with facilities and physicians individually. The system can be in network while the surgeon operating on you is not.
  • It's rebuilt every year. Last year's in-network doctor has to be re-checked this year. Nobody writes to tell you they left.

The practice decides acceptance

This part is invisible until you're on the phone with the front desk.

  • In network and accepting are not the same sentence. The directory can be completely accurate and the practice can still not be taking new patients on that plan.
  • Reimbursement is why. Where a plan pays practices less, they cap how many of its patients they carry. It isn't personal; it's a business deciding its mix.
  • Specialists are where it bites. Primary care you can usually find. The endocrinologist or the pediatric specialist with a waitlist is where it costs you.
  • You find out once you're enrolled and need the appointment. No comparison site measures how hard it is to get seen.

The test, and it takes ten minutes

Call the practice. Not the carrier, and not the directory.

For every doctor you plan to keep, give the exact plan name and plan year, and ask two questions, because one of them doesn't catch it:

  1. "Are you contracted with this exact plan?" The network question. The directory usually gets this one right.
  2. "Are you accepting new patients on it right now?" The acceptance question, the one nobody asks, and the one that decides whether you get seen.

Do it before you enroll, not after. It's the highest-value ten minutes in the whole process.

To be fair about it: not every Marketplace plan is narrow. Some counties have broad exchange PPOs, and where one exists it's often the right answer. And a private plan isn't automatically broader. It usually is, but usually is not checked.

07 · The thing that stops people even looking

Taking medication is not the same as being unhealthy.

This is the biggest misunderstanding about the private market, and people rule themselves out over it before anybody asks them anything. Most adults take something. What a carrier reads is context: what it's for, how long it's been stable, and whether anything about it is still moving.

01

Most of what walks through my door is approved.

Controlled blood pressure, a statin, a thyroid pill, managed reflux or migraines come up constantly and clear underwriting constantly. A medication that has done its job at the same dose for years is evidence the condition is controlled, which is close to the opposite of a red flag. A known quantity is the easy kind of risk to price.

The question was never "do you take anything."

The follow-ups decide it. Two people on the identical drug can get two different decisions, and the difference is almost always in the history behind it rather than the drug itself. Which is why nobody, me included, can tell you your answer from a list of your prescriptions.

And the answer isn't only yes or no.

A higher rate, one condition excluded, a waiting period: those are real outcomes worth looking at rather than walking away from. Read them slowly, and refuse one: an exclusion attached to the exact thing you were buying coverage for. That isn't a compromise. It's a plan with a hole cut exactly where you needed it.

A short list does close the door.

Active treatment, a recent cardiac event or stroke, a transplant or dialysis, surgery already scheduled, a symptom still being worked up. Those are declinable, and that's how this market works. But a no here means this lane isn't yours right now, not that you're out of options. The lane that can't refuse you is still open, and chapter 03 is why that's a good lane.

The one that's about coverage rather than approval

Mental health is where those two questions come apart.

An antidepressant that has worked for years is, in most cases, an ordinary answer on an application. What isn't the same is the benefit. The Marketplace carries therapy and psychiatry as standard. On the private side that depth often isn't matched, and it varies by carrier and state. So if somebody in the household is using that care every month, it can decide the market on its own, even where approval would have been fine.

It's situational every single time, and any page that tells you your answer is guessing. What I can do, before you fill in a formal application anywhere, is describe the household to a carrier's underwriting desk and ask what they'd likely do with it. That costs you nothing and it is not an application.

08 · The part about a year that hasn't happened

The two doors do not swing the same way.

This never comes up in a sales call, because it costs nothing today and everything later. For a healthy person it may be the most consequential idea on this page.

You can always come back to guaranteed-issue coverage. You cannot always come back to underwritten coverage.

Guaranteed-issue coverage stays available through its enrollment rules whatever your health: every open enrollment, every qualifying life event. Access to underwritten coverage depends on your health on the day you apply. Buying private while you're healthy gets you a price based on today's health, and if your health changes, that door may not open again.

That isn't an argument against private coverage. It's a reason to ask one question before you take it: is the policy guaranteed renewable? Meaning, can the carrier single you out and re-rate or drop you for getting sick while you keep paying? That answer belongs in the contract, and it's the difference between a plan that holds for a decade and one that holds right up until you need it.

The other kinds of flexibility

They cost real money, and none of them show up on a quote.

  • Portability. A plan you own follows you between jobs. A plan your employer owns ends the day the job does.
  • When you're allowed to move. Private plans can generally be applied for most of the year; the Marketplace runs on a season plus life events. In either one, changing your mind mid-year usually needs a qualifying event.
  • Income that moves. Commission, 1099, a strong year then a thin one. A subsidy is settled against what you earned, not what you estimated in January.
  • Geography. These are state products. If you might move or split the year between states, ask what happens to the network when you cross the line.

Which makes the timing question simple

Two households, same income, opposite answers.

  • If your life changes a lot (you contract, you move, your income swings, you're starting something), weight flexibility above price. The cheapest plan for January's life is often the wrong one by September.
  • If you're stable and expect to stay that way, let the network and the numbers decide. There's no sense paying for an option you'll never use.
  • If you're healthy and considering the private lane, you're spending an option to buy a price. That can be exactly the right trade. Just make it knowing that.

09 · Find your own household here

Almost everybody shops the wrong thing first.

They shop price, because price is the only thing comparable at a glance. But the markets are built for different households, and once you know which one is yours, the shopping gets easy. One of these seven is close enough to your house.

01 · Somebody is in active treatment

Care is being used every month, not just prescribed

Not "somebody takes a pill." Therapy every week, a condition still being managed closely, a specialist on a schedule. Approval often isn't the obstacle. Benefit depth is.

Where I'd startThe ACA Marketplace, and it isn't close. Nothing carved out, and mental health carried as ordinary medicine, is worth more than any premium saving.

02 · Income inside the band

The subsidy is the biggest number in your file

The credit is routinely larger than the whole difference between markets, and no amount of being healthy earns that back on the other side.

Where I'd startThe Marketplace. I'll run the other lane so you can see it, and then I'll tell you to stay where you are.

03 · Above the band, and healthy

High income, where being healthy earns you nothing

Self-employed, a business owner, or a household earning past the subsidies. You pay full price for the pool and get a county-sized network back, and most people here have never been shown what the other lane would charge.

Where I'd startThe private, underwritten market, with chapter 08 in mind. It's the only place your own health is allowed to work in your favor.

04 · Protecting what you've built

The family's exposure is the actual asset

The monthly premium was never the problem. You want a hard ceiling on a catastrophic year, a network that reaches the specialists you'd choose, and a structure that still holds in five years.

Where I'd startPrivate, and structured deliberately. Everything is sold on the monthly number, and none of what you're buying is monthly.

05 · Coverage through work

The company funds you well and the family thinly

Your own deduction is pre-tax and heavily subsidized. Add three dependents and the growth lands on your paycheck.

Where I'd startKeep yours. Quote the family. Get the dollar figure the company puts in per dependent, and everything else follows from it.

06 · Between things

A job just changed, or COBRA just quoted you

A new role, a layoff, a spouse's plan ending, a kid aging off at 26, a move. Losing coverage opens a special enrollment window. The window is short.

Where I'd startThe clock, before the market. Once the window closes your options narrow to whatever's left, and that's a much worse list.

07 · Turning 65, on disability, or a low income

Someone in the house qualifies for a government program

Medicare starts at 65, or earlier after a long-term disability. Medicaid covers low incomes, and each state draws its own line. Qualifying generally ends the Marketplace subsidy for that person, and Original Medicare on its own has no yearly ceiling on what you pay.

Where I'd startThe calendar and the income line. Medicare's first window opens three months before the 65th birthday, and missing it can mean a late penalty for as long as you have the coverage. Medicaid eligibility gets checked before anything else is quoted.

If two of those describe different people in your house, and that's extremely common, you're allowed to use both. It's the most under-used move in this business, because nobody tells people it's on the menu.

10 · Legal, sometimes useful, and not what you think

Some of what gets sold as health coverage isn't insurance at all.

These all exist, they're all legal, and several have a real use. They turn into a disaster in exactly one way: sold as a replacement for major medical to somebody who believes that's what they bought.

The one question that sorts all of them

"If I have a $300,000 year, what is the most I can be made to pay?"

Ask it exactly like that, and look for a number written into a contract. If the product can't answer it, it isn't doing the job major medical does, whatever else it may be worth to you. It's also the fastest way to tell an adviser from a salesperson: one answers it in a sentence, the other changes the subject to the monthly price.

  • Health care sharing ministries. Not insurance. Members share costs under the group's own guidelines, with no state insurance regulator, no guaranty fund and no legal obligation to pay your bill. Plenty of members are happy; a large claim is still decided by the ministry's rules, not a contract you can enforce.
  • Discount cards. Negotiated rates, not coverage. Useful at the margins, with no ceiling anywhere on what you can owe.
  • Short-term, limited-duration plans. Real insurance, but temporary, usually underwritten, and often excluding pre-existing conditions outright. Federal rules on how long they can run have changed more than once. As a bridge across a two-month gap between jobs, sometimes exactly right. As your plan for next year, no.
  • Fixed indemnity, accident and critical illness plans. A set payment when a specific thing happens. On top of real coverage they're good value, and they're in most of the packages in chapter 04. On their own they have no out-of-pocket maximum, so nothing limits what a bad year can cost you.

11 · If you take one thing from this page

Coverage that works for your household is worth more than a plan that satisfies the word "cheap."

the whole job, in one line

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. The flip side matters as much: the most expensive plan isn't automatically the safest, and plenty of people are over-insured for risks they don't have and under-insured for the ones they do. Fit is the whole game.

12 · Take this with you, even if you shop alone

What to look out for, in the order I'd look.

If you do nothing else on this page, use this list on whatever quote is in front of you. It works just as well on a quote that didn't come from me.

The out-of-pocket maximum, first

Before the premium, before the deductible. It's the ceiling on a catastrophic year, and it decides whether a bad year is expensive or ruinous.

Whether it's real major medical

Some products look like health insurance and are limited-benefit plans with caps per service. Ask directly, and be suspicious of anything whose headline is only the monthly price.

Your actual doctors, by name

Not the hospital system. The specific physicians, on this specific plan, for this year, and taking new patients on it.

What's excluded or carved out

On an underwritten plan especially. An exclusion on the exact condition you were buying coverage for is the worst outcome in this business, and reading is how you avoid it.

Whether the deductible is per person or per family

Very different numbers, often printed side by side in the same size type. Ask which one applies and when the family one kicks in.

What a specialist and an ER visit cost before the deductible

Copay or coinsurance? Does the copay count toward the deductible? This is where a "cheap" plan stops being cheap.

Your prescriptions on the plan's own drug list

Each by name, each at its tier. A drug on a bad tier, or off the list entirely, can outweigh every other difference between two plans.

Who you call in eighteen months

An agent who disappears after enrollment has told you something about how they got paid. Know whose number you're keeping before you sign.

13 · Why I give it away

The goal is free information.

If you can take everything on this page and work it out yourself, genuinely, good.

If you'd rather have somebody compare the real options with you, against your state, your health history and your doctors, that's what I do. It takes about twenty minutes and it costs nothing. And if the coverage you already have is the right answer, I'll tell you to keep it.

See my real options → Call (813) 833-2628