01
What private health insurance actually is
Private health insurance, in the sense used on this site, means an individual major-medical policy sold outside the government exchange by a nationally recognized carrier. It is a regulated insurance contract. A covered claim is a legal obligation, not a favor.
It is not a health sharing ministry, not a discount card, and not a short-term stopgap. Those are different products with different rules, and we compare against each of them honestly elsewhere on this site.
02
Underwriting: the part that matters most
ACA Marketplace plans are guaranteed issue. Everyone pays the same rate for the same plan at the same age in the same area, regardless of health history. That is a deliberate design: it spreads the cost of sick people across everyone.
Private plans are medically underwritten. The carrier asks about your health history and prices the policy on you specifically. If you are healthy, you are no longer subsidizing the pool, and the price reflects that — often dramatically. If you have a significant ongoing condition, the same mechanism works against you: a higher rate, a rider excluding that condition, or a declined application.
This single difference explains most of the price gap people notice, and it is why the honest answer to which is cheaper is always: it depends on your health and your income.
03
Pre-existing conditions
Plans in this market can and do cover pre-existing conditions — that is a real and important part of what a licensed advisor is checking for you. What varies is how a specific carrier treats a specific condition: covered at standard rates, covered at a higher rate, covered after a waiting period, or excluded.
Well-managed conditions are routinely accepted. Something diagnosed last month and still being worked up is a harder conversation. The only way to know is to have an advisor take your actual history to the carriers rather than guessing from a website.
04
PPO vs. HMO networks
A PPO lets you see any provider in a broad national network without a referral, and usually pays something toward out-of-network care. An HMO gives you a smaller local network, requires a referral to see a specialist, and generally pays nothing out of network except in an emergency.
The HMO is cheaper because the box is smaller. Whether that is a good trade depends entirely on whether your doctors — and the places you travel — are inside the box.
05
How to read a plan without getting lost
Four numbers do most of the work. Everything else is detail you can come back to.
- Premium — what you pay every month whether you use it or not
- Deductible — what you pay before the plan starts paying its share
- Copay and co-insurance — your share after the deductible is met
- Out-of-pocket maximum — the worst case in a plan year, and the number that actually protects you
06
What it costs
Rates depend on age, location, household size, health history and the plan chosen, so any single number on a website is not your price. The comparison used across this site — roughly $750 a month for an unsubsidized bronze Marketplace plan against roughly $300 for an underwritten PPO — reflects a healthy applicant, not a priced rate.
Your actual figure comes from an advisor running your details. That is a phone call, not a form result.
07
When private coverage is the wrong answer
There are several cases, and we would rather you hear them here than after you have bought something.
- You qualify for Medicaid — take it. It is free or near-free and no private plan competes.
- You qualify for a meaningful ACA subsidy — the subsidy almost always wins.
- You are pregnant or planning to be — maternity is an essential health benefit on ACA plans and is treated very differently here.
- You have a serious ongoing condition — guaranteed-issue coverage protects you in a way underwriting cannot.
- You are within a few months of 65 — Medicare is the plan you are waiting for.
08
How applying actually works
You share your state, household size, whether pre-existing conditions need covering, and your timing. A licensed advisor calls you, asks the health questions the carriers require, and comes back with what you actually qualify for and what it costs. You decide. There is no obligation at any point, and one advisor calls you — not a call center.
