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In the complicated arena of health insurance, we know half the battle of choosing a plan lies in understanding the various terms. Exploring the marketplace can be intimidating, especially for anyone doing so for the first time. But affordable health insurance is only a few clicks away. In Part 1 of our health insurance terms conversation, we highlighted some key definitions pertaining to enrollment. Today in our Part 2 segment, we’ll expand even further to shed light on terms relating to health insurance costs.

1. Upfront Costs to Consider

Buying a health insurance plan means having coverage and protections for the future. But when you’re considering costs, upfront affordability matters, too. As you browse the marketplace for providers and options, there are a few critical terms and conditions to consider. And many suggest looking for the big three expenses first – premiums, deductibles, and coinsurance.

Monthly Premiums

Enrolling in a health insurance plan also means signing up for monthly premium payments. These costs are in exchange for coverage and part of the annual agreement with the insurer. As of last year, the national average cost of an ACA monthly premium is around $456 for an individual and around $1,100 for a family. Your health insurance coverage doesn’t officially begin until you pay your first monthly premium. This amount can be drastically reduced should you qualify for premium tax credits. To see if you’re eligible, you can apply with your household information and income levels. Any discounts determined can be applied to the monthly premium of the plan you choose.

Copays & Deductibles

Another upfront and out-of-pocket expense to consider is a copay. Each health insurance plan available on the marketplace will outline any copay stipulations. This is a fixed expense you can expect to pay for a healthcare service, like a doctor’s visit or specialist appointment. These fees are usually due at the time of service and may apply towards the deductible. Copays can vary in range from $20 per occurrence to $100. And you will also have to consider a plan’s deductible, which is a set amount you can plan to be responsible for paying before your insurance kicks in with coverage.


Don’t be confused between copays and coinsurance. When you’re shopping for a health insurance provider, coinsurance costs will also need your consideration. Coinsurance refers to the percentage of a cost you share with the insurance provider, separate from the deductible or copay. For example, a $100 visit with your doctor might still cost you $20 even if you’ve met your deductible. Before officially enrolling in a plan, check to see what the provider’s requirements are for coinsurance percentages.

2. Health Insurance Costs That Go Overlooked

You might have a budget in mind when you shop for a new health insurance plan on the marketplace. In addition to those aforementioned upfront costs, there are other potential expenses to also consider. There are some health insurance costs you might overlook at first that will affect what you consider affordable.

Hospital Stays

While you don’t necessarily plan for emergency room visits or hospital stays, accidents do happen. It’s important to know what your chosen health insurance provider charges for in-patient hospital services. While the ACA requires all plans to cover emergency services, there are nuances to how some plans share costs of hospital stays. Some plans outline different pay schedules for such services that could leave you paying a hefty out-of-pocket amount, should you need them.

Specialist Appointments

You may have a general physician for yourself or your family without a need for any specialist visits. But before you select your marketplace insurance plan, make sure you understand any copays for specialists. You might have a $20 copay for your primary doctor. However, some plans insist on $50 or more for specialist visits. These providers could be ENT specialists, oncologists, or surgeons.

In-Network Providers

Another often overlooked cost is based on in-network versus out-of-network providers. Before making your health insurance plan selection, you’ll need to know if your healthcare professionals are part of the insurer’s network. Not verifying before you enroll could mean paying more or all of your doctor visits yourself or having to find a new in-network doctor instead.

3. Health Insurance Plan Extras That Are Free

Affordability is often determined by more than just out-of-pocket costs, deductibles, and premium payments. An ideal health insurance plan will also offer value based on your healthcare needs. There are essential health benefits, as defined by the Affordable Care Act, that health insurance plans provide for free. Some insurance providers offer even more covered services at no charge, making some plans even more valuable to some.


If you’re browsing for health insurance on the marketplace, you won’t have to worry about paying for vaccinations. Considered a preventive care step, many vaccines, including the flu shot, can be administered at no cost to you. These are provided without a copay, deductible, or coinsurance, as well.

Preventive Care Appointments

General practitioner visits for routine physicals are also considered essential health benefits. School-aged family members requiring physicals for sports are also preventive care appointments. To encourage your best healthy lifestyles, these types of visits will never be an out-of-pocket cost to you. Be mindful, however, that with some plans, these services are only free with in-network or participating doctors.

Screening & Scans

Under the general guidelines of the Affordable Care Act, all health insurance providers are also required to provide preventive screenings and scans at no charge to you nor cost-sharing. These include a variety of women’s services, including prenatal. Cancer screenings and mammograms are also covered as part of the annual preventive care plan.

Once you understand the terms and details describing the various costs and requirements for health insurance, the marketplace isn’t such a scary place. But if you’re still lacking confidence and are unsure about where to start or just have few questions about selecting the best-fit plan, contact us! Browsing the marketplace options with W3LL is free and puts all the tools at your fingertips to help you choose the best health insurance for you and your family this year.


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