Navigating Health Insurance in America: What You Need to Know Before You Enroll

When it comes to life in the United States, one of the most important—and often confusing—parts of settling in is understanding health insurance. Whether you’re a long-time resident or a new arrival, navigating the U.S. healthcare system can feel overwhelming.

Let’s get into it.

In this episode, I talked about how coverage really works, what your options are if you’re healthy or have a high income, and what to watch out for so you don’t get stuck with the wrong plan—or worse, overpay for coverage you don’t even need.

What You Need to Know About Enrolment

The Open Enrolment Period is your window to sign up for health insurance coverage.

Insurance plan prices have gone up again—but not drastically. In previous years, prices rose quickly. Recently, we’re seeing about a 4–4.5% increase overall.

• PPO plans: typically more expensive, and saw a higher increase
• HMO plans: more affordable, with a smaller bump in price

Here’s a quick breakdown:

• PPO (Preferred Provider Organization): an open network. No referral needed to see specialists. Accepted by about 95% of doctors and medical centers. Very convenient.
• HMO (Health Maintenance Organization): more restricted network. Requires a referral to see a specialist. Costs 15–20% less than PPOs but with more limitations.

If you’re 65 or older, there have been significant changes in recent years—and more are still unfolding.

Who’s Still Offering ACA (Obamacare) Plans?

In our region, Blue Cross is still the primary provider offering Affordable Care Act (ACA) plans. They offer:

• Personal Choice (PPO)
• Keystone (HMO)

Other companies like Aetna and UnitedHealthcare have exited the Marketplace in our area. They now focus only on private plans for healthy individuals.

In western PA and some other regions, there are a few new players:

• Geisinger
• Oscar (less known but recently joined the Marketplace)

So far, Blue Cross remains the most widely known ACA provider here.

Are ACA Subsidies Still Available?

Subsidies are still in place, but they’re shrinking.

• People who once received large subsidies are seeing reduced support.
• More and more folks are finding that their monthly premium has doubled—from $200–$300 up to $400–$600.

That’s why many are turning to alternative health plans.

How ACA Subsidies Work (And Why They’re Tricky)

Here’s the deal:

• You apply for ACA coverage based on a projected income.
• If your actual income ends up higher, you’ll need to pay back part of the subsidy.

Let’s say you estimate $50,000 for the year, and qualify for help. But then you earn $75,000? The IRS will recalculate and convert part of that subsidy into a tax credit repayment.

That’s why I always stress: If you’re not sure how much you’ll make next year, be cautious.

Real Insurance Costs—No Sugarcoating

Many people come to me saying they heard a friend or neighbor got full family coverage for $95/month. And yes—that’s possible if you qualify for a large subsidy.

But without a subsidy, coverage is expensive.

For a family of four:

• With ACA: $1,500–$2,000/month
• Without a subsidy, you pay the full amount out of pocket

If your household income is over $100,000, you likely won’t qualify for any assistance.

Affordable Alternatives for Healthy Families

If you’re in good health and don’t qualify for subsidies, alternative health plans may save you a lot of money.

Let’s break it down:

• A couple in their 30s with two kids
• Alternative plan: $350–$400/month
• ACA equivalent: $1,500/month or more

That’s a $1,000/month savings.

Even HMO versions of these plans can be 15% cheaper than PPOs.

But here’s the tradeoff:

• These plans don’t cover maternity or pregnancy
• No OB/GYN visits related to pregnancy
• Chronic conditions may be excluded or lead to denial

So if you’re healthy and not planning to have a baby soon, these plans can be a great option. Just read the terms carefully.

Read the Fine Print (Or Talk to a Broker)

Every plan is different. Some exclude cosmetic procedures. Some exclude psychiatric treatment.

People often buy a plan thinking it covers everything—and later realize it doesn’t.

That’s where brokers come in. Our job is to:

• Answer your questions
• Look at your specific health and income situation
• Help you pick a plan that’s the right fit

You don’t always have time to read contracts line by line—that’s our job.

And no, I don’t charge a fee for my services. But if extra work is needed, like handling paperwork or appeals, a fee may apply. I’ll always be upfront with you.

eHealth20‘s mission is to make sure every client is fully informed.

So don’t hesitate—call me at  215-690-5006 with your questions. Everyone’s situation is different:

• Income
• Family size
• Health conditions

The more you know, the better your choices.