Insurance 101 — Mantz Health

The Basics

Four words worth actually knowing

Premium

What you pay every month just to have the plan — whether you use it or not.

Deductible

What you pay out of pocket before your insurance starts covering costs.

Max Out-of-Pocket

The most you'll pay in a year — after that, your plan covers 100% of the rest.

Copay vs. Coinsurance

A copay is a flat fee (like $30/visit). Coinsurance is a percentage split with your insurer.

Network Types

HMO vs. PPO

The two most common network structures — here's the real difference.

	HMO	PPO
See a specialist	Needs a referral	No referral needed
Out-of-network care	Usually not covered	Often covered
Monthly premium	Usually lower	Reflects your health profile
Best for	Simplicity, lower cost	Flexibility & broader access

The Big Comparison

Marketplace vs. Private

ACA Marketplace

Based onYour household income
Risk poolLarge, shared pool — cost isn't based on your health
ApprovalGuaranteed issue — everyone is accepted
Watch out forCosts can rise fast if you don't qualify for subsidies

      Private Plans
      Based onYour personal health profile
Risk poolPriced individually — healthy applicants often rewarded
Tax benefitOften tax-deductible for the self-employed
ApprovalSubject to health underwriting

    

Why healthy people often pay more than they should

Most people don't realize their current plan — an ACA Marketplace plan, COBRA, or a typical employer group plan — uses what's called community rating. Everyone in the pool pays a similar price based mainly on age and location, regardless of individual health. It's a fair system, but it also means healthy people often help cover the cost of less-healthy people in the same pool.

Private PPO plans work differently — they're medically underwritten, meaning your rate is based on your own health profile. It works a lot like car insurance: a safe driver pays less than someone with tickets and accidents, because the price reflects their actual risk. If you're healthy, a medically underwritten plan is often built to reward exactly that, with lower premiums than a community-rated plan would offer.

This is why two people with the same income can end up paying very different prices for very different reasons — and why it's worth having someone check both sides before assuming you're already on the cheapest option.