american-medical-plans

February News Letter

Thu, 05 Feb 2026 06:00:11 GMT

The Freelancer’s Survival Guide to 2026 Health Coverage

Being your own boss is liberating, but it also means navigating the complex world of health insurance without an HR department to guide you. For freelancers, consultants, and gig workers, 2026 brings some significant shifts that could impact your coverage and your wallet. Gone are some of the enhanced subsidies and certain Special Enrollment Periods (SEPs) that many relied on. But don't panic! This guide is your roadmap to securing solid private health insurance in 2026, ensuring you stay covered and financially protected.

The Big Changes for 2026: What You Need to Know

The biggest headline for individual health insurance in 2026 is the expiration of the enhanced Affordable Care Act (ACA) subsidies . While these subsidies previously made marketplace plans significantly more affordable for many, their reduction or elimination means you might see a noticeable jump in your monthly premiums.

Additionally, some of the more flexible Special Enrollment Periods (SEPs) tied to specific low-income thresholds have also been adjusted or removed . This means accurately reporting your income and planning ahead during Open Enrollment is more crucial than ever.

The takeaway: Proactive planning and a clear understanding of your income are your best friends this year.

Your 2026 Health Insurance Checklist:

1. Master Your Income Projection (It's More Important Than Ever!)

For freelancers, income can fluctuate wildly. However, your projected Adjusted Gross Income (AGI) is the primary factor determining your eligibility for any subsidies on the Health Insurance Marketplace.

Be Realistic, Not Optimistic: When estimating your 2026 income for your marketplace application, be as accurate as possible. Overestimating means you might miss out on subsidies you're eligible for, while underestimating could lead to owing money back at tax time.
Track Everything: Keep meticulous records of all your income and deductible business expenses. This will make your projection more accurate and simplify tax season.
Update as Needed: If your income significantly changes during the year, update your information on the marketplace website immediately. This can adjust your subsidies and prevent surprises.

2. Don't Miss Open Enrollment (Your Primary Window)

Open Enrollment is your annual opportunity to enroll in a new plan or change your existing one, regardless of any life changes. For 2026 coverage, Open Enrollment typically runs from November 1st to December 15th, 2025 , for coverage starting January 1st, 2026.

Mark Your Calendar: Treat these dates like client deadlines. Missing Open Enrollment means you generally cannot get private health insurance until the next year unless you qualify for an SEP.
Review Your Options: Even if you liked your plan last year, new plans emerge, and existing ones change their benefits, networks, and prices. Always shop around.

3. Explore All Your Private Health Insurance Avenues

Beyond the ACA Marketplace, freelancers have other options to consider:

The ACA Marketplace (Healthcare.gov or State Exchanges): This is still often the best place to find comprehensive, subsidized plans if your income qualifies. You can compare plans side-by-side, understand your potential subsidies, and enroll easily.
Direct from Insurers: You can purchase plans directly from private insurance companies. These plans might not offer the same subsidies as marketplace plans, but they can sometimes provide different network options or specialized coverage.
Professional Organizations & Associations: Many freelance unions, guilds, or professional associations offer group health insurance options to their members. These can sometimes provide better rates or more tailored benefits.
Health Share Ministries: These are not insurance but are organizations where members share healthcare costs based on religious or ethical beliefs. They often come with lower monthly "share" amounts but have different coverage rules and may not cover certain pre-existing conditions. Research these thoroughly to understand their limitations.
Short-Term Health Insurance (Use with Caution): These plans offer temporary coverage for a limited period (e.g., 3-12 months) and are generally much cheaper. However, they don't have to cover the ACA's essential health benefits, often don't cover pre-existing conditions, and have caps on coverage. They are best used as a bridge between comprehensive plans, not a long-term solution.

4. Understand Your Plan Types: Deductibles, HSAs, and Copays

Knowing the lingo helps you choose the right fit:

High-Deductible Health Plans (HDHPs) with Health Savings Accounts (HSAs): These plans have lower monthly premiums but require you to pay more out-of-pocket before insurance kicks in. The magic is the HSA – a tax-advantaged savings account you can use for qualified medical expenses. The money rolls over year to year and can even be invested. This is often an excellent option for healthy freelancers who want to save on premiums and control their healthcare spending.
PPOs, HMOs, and EPOs: Understand the differences in provider networks and referral requirements.
PPO (Preferred Provider Organization): More flexibility to see out-of-network providers, but usually with higher costs.
HMO (Health Maintenance Organization): Typically lower costs, but requires you to choose a primary care physician (PCP) and get referrals to specialists.
EPO (Exclusive Provider Organization): A hybrid, offering a network like an HMO but generally without PCP referrals.

5. Consider a Catastrophic Plan (If You Qualify)

If you're under 30 or have a hardship exemption, you might be eligible for a Catastrophic health plan on the marketplace. These plans have very low premiums but extremely high deductibles. They're designed to protect you from truly devastating medical bills, not routine care. They can be a lifeline for young, healthy freelancers on a tight budget.

Don't Go Without Coverage!

While the changes in 2026 might make health insurance feel more challenging for freelancers, going without coverage is a risky gamble that could derail your financial future. A single unexpected illness or accident could wipe out your savings and put your freelance career on hold indefinitely.

Take the time now to research, compare, and choose a plan that fits your needs and budget. Your future self (and your bank account) will thank you.

Joel Smith

American Medical Plans, Inc.

Don't Lose Time

Tue, 13 Jan 2026 19:31:17 GMT

Is Doing Nothing Costing You? Why Your Retirement Strategy Needs More Than "Hope"

If managing your finances feels confusing, you aren't alone. Most people were never taught the actual mechanics of wealth preservation. Instead, we are fed slogans like “invest for the long run” or “ride out the market volatility.”

While that sounds responsible, it ignores one critical factor: Time.

When your portfolio loses value—even temporarily—you aren't just losing dollars; you are losing the time it takes to recover. In retirement planning , lost time is the most expensive hidden cost you can face. This blog explores why "doing nothing" is actually a high-risk decision and how you can shift from a strategy of hope to a strategy of certainty.

The Problem with Traditional Retirement Strategies

Most financial plans are built on three "hopes" that are entirely out of your control:

Market Cooperation: Hoping the stock market stays bullish during your sensitive transition years.
Perfect Timing: Hoping your retirement date doesn't align with a global economic crash.
Sequence of Returns: Hoping you don't have to drain your accounts while the market is down.

Hope is not a strategy. As you approach retirement, your financial goals must shift. You no longer need "potential"—you need predictable income , reduced risk, and a plan that doesn't rely on perfect market timing.

The Psychological Cost: Why "Market Noise" Is Your Silent Enemy

Beyond the math of retirement, there is a mental toll that traditional investing often ignores. When you are in your 30s, a market dip is a "sale." When you are 62, a market dip feels like a threat to your freedom.

This psychological pressure often leads to the most damaging financial mistake: Reactive Decision Making. When the market becomes volatile, the human instinct is to protect what remains. If you don’t have a strategy that accounts for protection, you are more likely to sell at the bottom, locking in losses and losing the time required for that capital to ever recover.

The Million Dollar Hour™ is designed to remove this emotional weight. By identifying which assets are "performing" (growth-oriented) and which are "protected" (income-oriented), you can ignore the 24-hour news cycle. You gain the freedom to enjoy your retirement without checking the S&P 500 every morning.

The Strategic Advantage: Why Annuities Are Often the "Missing Piece"

When people hear the word "annuity," they often think of complex contracts. However, in the context of a fully performing asset , a modern annuity is simply a tool designed to do one thing that the stock market cannot: Guarantee the outcome.

If your goal is to stop losing time, here are the four primary benefits of incorporating annuities into your retirement forecast:

1. Eliminating "Sequence of Returns" Risk

The biggest threat to your retirement isn't a market crash—it’s a market crash at the wrong time. If the market drops 20% the year you retire, your "time to recovery" could be a decade or more. Certain annuities provide a 0% floor , meaning when the market goes backward, your principal stays put.

2. Creating a "Personal Pension" for Life

We live in an era where company pensions have vanished. Most retirees are forced to guess how much they can safely withdraw from a 401(k) without running out of money. A guaranteed lifetime income rider transforms a portion of your savings into a predictable "paycheck" that arrives every month, regardless of how long you live.

3. Contractual Growth vs. Hypothetical Growth

Mutual funds offer hypothetical growth—you might make 8%, or you might lose 12%. Annuities offer contractual growth. Many fixed-indexed annuities allow you to participate in the upside of market indexes without being exposed to the downside.

4. Emotional ROI (The "Sleep Insurance" Factor)

Knowing that your essential expenses—mortgage, groceries, healthcare—are covered by a guaranteed income stream allows you to be more relaxed with the rest of your portfolio.

Common Questions About Protected Growth

Aren't annuities "expensive" or "locked up"? This is a misconception based on outdated products. Modern annuities offer significant liquidity features, typically allowing you access to 10% of your money annually without penalties.

What happens to my money if I die early? Unlike old-fashioned pensions, most modern annuities include a death benefit. This ensures that any remaining principal goes directly to your beneficiaries, often bypassing the long and expensive probate process.

How do I know if I’m "over-exposed" to risk? Most people are surprised to find their 401(k) is 100% exposed to market fluctuations. During our session, we use a "Risk Stress Test" to show you exactly how much your portfolio would drop in a repeat of 2008 or 2022.

Introducing the Million Dollar Hour™: A Smarter Way to Forecast

The first step to a secure retirement isn't buying a product; it’s understanding the opportunity cost of your current strategy.

We offer the Million Dollar Hour™ , a personal financial forecast designed to give you total clarity. In this one-hour session, we help you:

Calculate Lost Time: See exactly how much time your current strategy may be costing you.
Identify Hidden Risks: Uncover vulnerabilities in your portfolio hiding in plain sight.
Explore Fully Performing Assets: Learn how specific assets provide stability and growth.
Get Jargon-Free Clarity: Walk away with a clear picture—without high-pressure sales tactics.

Summary: The Difference Between a Portfolio and a Plan

A portfolio is a collection of tickers and symbols. A plan is a documented strategy that ensures you have enough money to live the life you want, no matter how long that life lasts.

The goal of our work isn't just to help you accumulate wealth—it's to help you distribute it efficiently. We want to ensure that your "Go-Go Years" are funded, your "Slow-Go Years" are secure, and your "No-Go Years" are fully prepared for.

The goal isn’t just to get rich. It’s to stop losing time.

Author: Frank Day In partnership with American Medical Plans

(682) 348-5610

Info@americanmedicalplans.com

Americanmedicalplans.com

The "ACA" Cliff

Wed, 07 Jan 2026 16:23:51 GMT

The ACA “Cliff” is Here:

Why 2026 is the Year to Move to Private Health Coverage

For years, the Affordab le Care Act (ACA) has been propped up by temporary government "band-aids." But on January 1, 2026, those band-aids were officially ripped off.

Despite months of political gridlock, government shutdowns, and empty promises from Washington, the enhanced tax credits that millions relied on have expired. The result? A "full suffocation" of the American middle class, with health insurance premiums doubling, tripling, or even quadrupling overnight.

At American Medical Plans , we believe you shouldn't have to choose between keeping your lights on and having health insurance. If you are a small business owner, a freelancer, or a healthy family, here is why 2026 is the year to skip the ACA and look toward the private market.

1. The Death of the Subsidy: A 114% Premium Hike

According to recent data from KFF, the average ACA enrollee is seeing a staggering 114% increase in premium costs this year.

We are seeing real-world stories of single mothers whose monthly payments jumped from $85 to $750. When "affordable" is in the name of the law but the price tag is $9,000 a year just for the premium (before you even hit your deductible), the system is broken. By moving to a private plan, you can often secure rates based on your health status rather than being forced to subsidize a failing government pool.

2. The "Sicker" Pool Problem

As subsidies vanish, experts at the Urban Institute project that nearly 5 million Americans —mostly the young and healthy—will drop ACA coverage entirely.

This creates a "death spiral." When healthy people leave the Exchange, only the most expensive, high-risk patients remain. To cover those costs, carriers must raise rates even higher for those who stay. By staying in the ACA pool, you are essentially paying a "health tax" to cover the rising costs of a dwindling, sicker population.

3. Carriers Are Fleeing: Is Your State Next?

It isn't just the enrollees who are leaving; insurance companies are looking at the math and heading for the exits. As the market becomes less stable and the "risk pool" worsens, major carriers have begun scaling back or completely withdrawing from the Exchange in several states.

While the landscape is shifting daily, significant carrier exits or plan reductions have been noted in:

Texas & Florida: High-growth states where the sheer volume of unsubsidized middle-class earners is making ACA plans unsustainable.
The Midwest (Wisconsin, Iowa): Rural areas are seeing a "monopoly effect" where only one carrier remains, leading to zero price competition.
The West (Utah, Arizona): States where freelance and gig-economy workers are being priced out, causing carriers to rethink their participation.
The Southeast (Georgia, North Carolina): States where the gap between the "fully subsidized" and the "self-paid" has become a chasm.

4. Washington Isn’t Coming to Save You

While some in Congress are pushing for a vote in late January to revive the credits, the reality is a stalemate. The Senate has already rejected extensions, and the House remains divided.

Relying on a House vote for your family’s physical and financial health is a massive risk. Can you afford to pay $700+ a month for the next three or four months while waiting for a "maybe" from a politician?

The Alternative: Private, Underwritten Coverage

At American Medical Plans , we specialize in helping the "middle-class squeeze" find a way out. Private plans offer several advantages the ACA can’t match in 2026:

Locked-in Rates: No more wondering if a tax credit expiration will double your bill next year.
Health Rewards: If you are healthy, you should pay less. Our plans reward your lifestyle.
PPO Networks: Tired of the "HMO" restrictions on the Exchange? Access the doctors and specialists you actually want to see.
Year-Round Enrollment: You don't have to wait for a "window" to save money.

Take Control of Your Healthcare Today

The era of "free" government healthcare is ending for millions, leaving the middle class to pick up the tab. Don’t wait for a January vote that may never come.

Contact American Medical Plans today for a free quote. Let us show you how much you can save by stepping away from the ACA and into a plan designed for your life, your budget, and your future.

Mid-November Blog: Diversify!

Fri, 21 Nov 2025 17:20:15 GMT

Diversify!

The Family Plan Fallacy: Why Splitting Your Health Coverage Could Save You Thousands

When Open Enrollment season rolls around, most families operate on autopilot. You look at the options, select "Employee + Spouse" or "Employee + Family," and grit your teeth when you see the monthly premium deducted from your paycheck.

We are taught that bundling is better. We bundle home and auto insurance; we bundle internet and cable. But in the complex world of health insurance, bundling your family onto one plan is often a financial mistake.

It is time to consider diversifying your insurance portfolio . Here is why splitting your family across two different health plans—or even two different insurance carriers—might be the smartest financial move you make this year.

1. The "Spousal Surcharge" and Subsidy Caps

The biggest driver for splitting coverage is how employers subsidize premiums.

Many companies pay a significant portion (sometimes 100%) of the premium for the employee , but contribute significantly less for dependents .

The Scenario: Your employer pays $500 toward your premium, making your individual cost $50/month. However, adding a spouse jumps the premium to $600/month because the employer contributes nothing toward them.
The Surcharge: Some companies now charge an explicit "spousal surcharge" (often $100–$150 extra per month) if your spouse has access to insurance through their own job but chooses to be on yours instead.

The Strategy: If both partners work, compare the cost of two individual "employee-only" plans against one "family" plan. You may find that two subsidized individual plans are cheaper than one family plan carrying the full weight of unsubsidized dependents.

2. Matching Plans to Medical Needs

In many families, health profiles differ drastically. One person might manage a chronic condition, requiring frequent specialist visits and prescriptions, while the other only visits the doctor for an annual physical.

If you put everyone on a high-coverage (and high-premium) PPO plan, you are over-insuring the healthy members . If you put everyone on a low-premium High Deductible Health Plan (HDHP), you might be under-insuring the member with chronic needs .

The Strategy:

Partner A (High Needs): Joins a Low-Deductible PPO or HMO. Higher premium, but lower costs at the doctor's office.
Partner B (Low Needs): Joins an HDHP (High Deductible Health Plan). Low premium, and eligibility to open a Health Savings Account (HSA) to save tax-free money for the future.

3. Navigating Provider Networks

Does your pediatrician love Blue Cross, but your cardiologist is exclusively in the United Healthcare network?

When you force the whole family onto one plan, someone usually has to give up their preferred doctor or pay expensive out-of-network rates. By diversifying, you can ensure that each family member is on a plan that includes their "must-have" medical providers.

The Math: A Hypothetical Case Study

Let’s look at the "Smith" family (two adults, no kids).

Option A: The Bundle They join the husband's plan.

Premium: $750/month (Employee + Spouse).
Total Annual Cost: $9,000.

Option B: The Split The husband stays on his plan; the wife joins her employer’s plan.

Husband's "Employee Only" Premium: $100/month.
Wife's "Employee Only" Premium: $150/month.
Total Monthly Cost: $250.
Total Annual Cost: $3,000.

The Savings: $6,000 per year. Even if the wife's deductible is slightly higher, the guaranteed $6,000 savings in premiums covers a lot of medical bills.

The Risks: What to Watch Out For

Splitting the family isn't a magic bullet for everyone. Before you uncheck the "Family" box, consider these factors:

Two Deductibles: You will now have to meet two separate deductibles. If you have a catastrophic year (e.g., a car accident involving both partners), you have to satisfy both individual maximums rather than one family maximum.
Administrative Fatigue: You will be managing two portals, two insurance cards, and two sets of paperwork.
The "Family" Out-of-Pocket Max: Large families (parents + multiple kids) usually benefit from a "Family Out-of-Pocket Maximum." Once one or two people hit the cap, the rest of the family gets free care for the year. If you split up, you lose this aggregate protection.

The Bottom Line

Insurance is a game of risk management. Don't assume that togetherness equals savings. Take an hour this Open Enrollment season to open spreadsheets for both spouses' benefits packages.

Look at the premiums, check the subsidies, and assess your actual health usage. You might find that a little bit of separation is the key to a healthier bank account.

Quinn Lewis

American Medical Plans, Inc.

November 2025 Newsletter

Mon, 03 Nov 2025 16:18:59 GMT

Navigating the Open Enrollment Maze: Why a Private PPO Plan Is Your Best Bet for 2026

O pen Enrollment season is upon us, and with it comes the annual headache of navigating a complex sea of health insurance options. You’ve heard the acronyms—HMO, EPO, POS—but the one that should be at the top of your list, especially with the storm clouds gathering over the ACA marketplace, is PPO , or Preferred Provider Organization.

As we look toward 2026, the Affordable Care Act (ACA) marketplace is facing a potential pricing earthquake. The enhanced premium tax credits (subsidies) that have shielded millions from high costs are set to expire. The result? Projections show a massive spike in ACA premiums, with some estimates pointing to median increases of 18% to 20% or more .

This impending "subsidy cliff" will hit middle-income individuals and families the hardest—precisely those who earn just enough to be disqualified from assistance. If you're one of them, you’re about to be fully exposed to the high costs of marketplace plans, all while potentially being locked into a restrictive network.

This is why, now more than ever, it’s time to seriously consider the stability, flexibility, and long-term value of a private PPO plan.

The Problem with Other Plans: A Quick Rundown

Before praising the PPO, let’s look at the alternatives you’ll find on the marketplace. These plans are often cheaper, but that savings comes at a significant cost: your freedom.

HMO (Health Maintenance Organization): This is the most restrictive option. You must choose a Primary Care Physician (PCP) from within their network. This PCP acts as a "gatekeeper," meaning you need a referral from them just to see a specialist, like a dermatologist or a cardiologist. Want to see a doctor outside their small, local network? Forget about it. Unless it's a life-threatening emergency, you’re paying 100% of that bill yourself.
EPO (Exclusive Provider Organization): An EPO is a slight step up. You generally don't need a referral to see a specialist. However, just like an HMO, it’s an "exclusive" network. You have zero coverage for any out-of-network provider. If your trusted doctor or a highly-rated specialist isn't on their list, you're out of luck.
POS (Point of Service): This plan tries to be a hybrid. Like an HMO, you typically need to pick a PCP and get referrals. It offers some out-of-network coverage, but the paperwork is burdensome, and the reimbursement rates are often frustratingly low, leaving you with surprise bills.

The PPO Difference: Paying for Freedom and Control

This brings us to the PPO (Preferred Provider Organization) . A PPO is built on one simple, powerful concept: choice . It is the premium option for those who value autonomy over their own healthcare decisions.

Yes, the monthly premium is typically higher than an HMO's. But what you are buying with that premium is invaluable.

1. Unmatched Network Flexibility

A PPO has a large "preferred" network of doctors and hospitals, but its defining feature is its out-of-network coverage .

Stay In-Network: You get the highest level of coverage and lowest costs by using doctors and hospitals within the PPO network.
Go Out-of-Network: Want to see a specific specialist who isn't on the list? Need to see a doctor while traveling? No problem. The PPO plan will still pay a portion of the bill . You’ll have a higher copay or coinsurance, but you won't be stuck paying the entire cost, unlike with an HMO or EPO. This peace of mind is the PPO's greatest strength.

2. No Referrals, No Gatekeepers

With a PPO, you are in the driver's seat. You do not need to select a Primary Care Physician and, most importantly, you never need a referral to see a specialist.

If you wake up with a suspicious-looking mole, you can call and book an appointment with a dermatologist directly. If your knee is acting up, you can go straight to an orthopedist. You don't need to book an initial appointment with a PCP just to get permission to see the doctor you actually need. This saves you time, money (in the form of an extra copay), and frustration.

The 2026 ACA Warning: Why PPOs Are a Smarter Haven

The flexibility of a PPO is always valuable, but it becomes critically important in light of the looming ACA crisis.

The ACA marketplace has provided a crucial safety net, especially for those with pre-existing conditions or lower incomes. But for healthy individuals and families who earn a decent living, that "safety net" is about to be pulled away.

When the enhanced subsidies expire at the end of 2025, anyone earning over 400% of the federal poverty level (roughly $60,240 for an individual or $124,800 for a family of four) will likely lose their subsidy entirely. You'll be asked to pay the full, unsubsidized premium for an ACA plan—a price that is set to skyrocket.

Why pay a skyrocketing premium for a restrictive HMO or EPO plan when, for a similar price, you could have a private PPO?

With a private PPO, your premium is based on your health and the plan's benefits, not on a volatile, subsidy-driven market. You are buying a high-quality, stable insurance product that gives you control. You get a nationwide network, the freedom to see specialists, and the security of knowing you are covered even if you step out of network.

As you enter Open Enrollment, think beyond the sticker shock of the monthly premium. Calculate the true cost. Consider the co-pays for extra gatekeeper visits, the financial risk of a plan with no out-of-network coverage, and the sheer frustration of being denied care you want.

With ACA premiums set to jump, 2026 is the year to opt out of the restrictive marketplace maze and invest in the superior freedom of a PPO.

References

Anthem. (n.d.). Types of health insurance plans. Retrieved October 28, 2025, from https://www.anthem.com/individual-and-family/insurance-basics/health-insurance/types-of-health-insurance-plans
CalPERS. (2024, September 16). HMO, PPO, and EPO: What's the difference and why does it matter? CalPERS News. https://news.calpers.ca.gov/hmo-ppo-and-epo-whats-the-difference-and-why-does-it-matter/
Cigna. (n.d.). What is PPO insurance? Retrieved October 28, 2025, from https://www.cigna.com/knowledge-center/what-is-ppo-insurance
Cox, C., & Long, M. (2025, August 6). How much and why ACA Marketplace premiums are going up in 2026. KFF. https://www.healthsystemtracker.org/brief/how-much-and-why-aca-marketplace-premiums-are-going-up-in-2026/
Healthcare.gov. (n.d.). Health insurance plan & network types: HMOs, PPOs, and more. Retrieved October 28, 2025, from https://www.healthcare.gov/choose-a-plan/plan-types/
Healthcare.gov. (n.d.). Private plans outside the Marketplace outside Open Enrollment. Retrieved October 28, 2025, from https://www.healthcare.gov/private-plan-exceptions-outside-open-enrollment/
Healthcare Insider. (2025, October 22). Why did my ACA premium go up? 5 factors driving 2026 rate hikes. https://healthcareinsider.com/why-will-my-health-insurance-premium-go-up
HealthPlusLife. (2025, October 13). Why private health insurance costs differ from Marketplace plans. https://healthpluslife.com/health-insurance/private-health-insurance-costs-from-marketplace-plans/
KFF. (2025, October 28). 8 things to watch for the 2026 ACA Open Enrollment Period. https://www.kff.org/affordable-care-act/8-things-to-watch-for-the-2026-aca-open-enrollment-period/
Medicare Rights Center. (2025, August 7). Affordable Care Act Marketplace premiums expected to skyrocket. https://www.medicarerights.org/medicare-watch/2025/08/07/affordable-care-act-marketplace-premiums-expected-to-skyrocket
Terry Family Insurance. (n.d.). ACA vs. private health insurance: Which plan saves you more? Retrieved October 28, 2025, from https://terryfamilyinsurance.com/aca-vs-private-health-insurance-which-ones-right-for-you/
Thompson, C. (2025, October 22). Health insurance sticker shock begins as shutdown battle over subsidies rages. The Washington Post. https://www.washingtonpost.com/health/2025/10/22/obamacare-aca-enrollment-price-increases/
UnitedHealthcare. (n.d.). What are HMO, PPO, EPO, POS and HDHP health insurance plans? Retrieved October 28, 2025, from https://www.uhc.com/understanding-health-insurance/types-of-health-insurance/understanding-hmo-ppo-epo-pos

Quinn Lewis

American Medical Plans, Inc.

October 2025 Newsletter: Getting Ready for Open Enrollment

Thu, 02 Oct 2025 14:34:29 GMT

Getting Ready for Open Enrollment

Open Enrollment is starting up. This is your annual opportunity to choose or change your health insurance plan for the upcoming year. Making the right choice can save you money and ensure you have the coverage you need. Here’s how to get ready for open enrollment in 2025.

What is Open Enrollment?

Open enrollment is a specific window of time each year when you can sign up for a new health insurance plan or make changes to your existing one. Whether you get insurance through your job, the Affordable Care Act (ACA) Marketplace, or Medicare, this is your primary chance to make adjustments. If you miss this window, you generally can't enroll in a new plan until the next open enrollment period unless you experience a qualifying life event, like getting married or losing other health coverage.

Mark Your Calendar: Key 2025 Dates

While dates can vary, especially for employer-sponsored plans, here are the typical open enrollment periods to watch for:

Affordable Care Act (ACA) Marketplace: The federal Marketplace (HealthCare.gov) open enrollment period starts on November 1st, and ends on January 15th.
Employer-Sponsored Plans: Most companies hold their open enrollment in the fall, often during October or November, for coverage starting January 1. Check with your HR department for your company's exact dates.
Medicare: The Medicare Annual Enrollment Period runs from October 15, 2025, to December 7, 2025 . This is the time for beneficiaries to change their Medicare Advantage or Part D prescription drug plans.
Marketplace Coverage Effective Date: If you’ve changed, or just enrolled in, a marketplace plan, your first premium and coverage period starts on February 1st.

Your 5-Step Preparation Checklist

Don't wait until the deadline is looming. A little preparation can make the process smooth and stress-free.

Review Your Current Coverage: Think about the past year. Were you happy with your plan? Did it cover your doctors and prescriptions? Were the out-of-pocket costs manageable? Note what worked and what didn't.
Anticipate Next Year's Needs: Consider any life changes on the horizon. Are you planning to have a baby, expecting a change in income, or managing a new health condition? Your future needs are a key factor in choosing the right plan.
Gather Your Information: Have the essentials ready for everyone you're enrolling. This includes Social Security numbers, birth dates, and recent income information (like pay stubs or W-2s).
Know the Lingo: Understanding key terms is crucial for comparing plans.

Premium: The fixed amount you pay each month for coverage.
Deductible: The amount you must pay for covered services before your insurance starts to pay.
Copay: A fixed amount you pay for a covered service, like a doctor's visit.
Coinsurance: The percentage of costs you pay for a covered service after you've met your deductible.
Out-of-Pocket Maximum: The most you'll have to pay for covered services in a plan year. After you hit this amount, your insurance pays 100%.
PPO: Proffered provider network. This means the plan will cover any doctor you may choose to go to.
HMO: Health maintenance organization. This means you'll have a set list of doctors that are contracted with your plan.

Set Your Budget: Look beyond the monthly premium. A plan with a low premium might have a high deductible, meaning you'll pay more upfront for care. Calculate what you can realistically afford for both monthly payments and potential out-of-pocket expenses.

Making Your Final Choice

Once you've done your homework, it's time to compare your options.

Check the Network: Make sure your preferred doctors, hospitals, and specialists are "in-network" to avoid high out-of-network costs.
Verify Prescription Coverage: Use the plan's drug formulary (list of covered medications) to ensure your prescriptions are covered at a reasonable cost.
Look at Total Costs: Don't just pick the plan with the lowest premium. Consider the deductibles, copays, and out-of-pocket maximum to estimate your total potential cost for the year.
Don't Be Afraid to Ask for Help: If you're using the ACA Marketplace, free help is available from certified assisters or "navigators." If you're choosing a plan through work, your HR department is your best resource.

Open-Enrollment Alternatives

1. The Enrollment Window: Open Enrollment vs. Year-Round Access

ACA Marketplace Plans (Relying on Open Enrollment): These are the plans available through government exchanges like HealthCare.gov. Enrollment is restricted to the annual Open Enrollment Period (OEP) , typically from November 1st to January 15th in most states. The only way to enroll outside of this window is if you have a Qualifying Life Event (QLE), such as losing your job, getting married, or moving, which grants you a Special Enrollment Period (SEP) .
Private Market Alternatives: Many plans sold directly by insurance companies or through private brokers are available for purchase year-round. This is a significant advantage for individuals who miss the OEP and do not have a QLE. This category includes everything from fully ACA-compliant plans sold "off-exchange" to other types of coverage like Short-Term Medical plans. This directly addresses your point about being "able to make changes to your coverage throughout the year."

2. Provider Networks: The PPO vs. HMO Dominance

This is one of the most significant distinctions and a major driver of consumer choice.

PPO (Preferred Provider Organization): This type of network offers the most flexibility. You can see any doctor you wish, both in-network and out-of-network. You don't need a referral from a primary care physician (PCP) to see a specialist. While staying in-network is cheaper, you still have coverage (at a higher cost) if you go out-of-network.
HMO (Health Maintenance Organization): This network is more restrictive and generally more affordable. You must use doctors, hospitals, and specialists within its network (except in an emergency). You are also typically required to have a PCP who must give you a referral before you can see a specialist.

Why the Difference?

Marketplace Plans are Predominantly HMOs: To keep premiums affordable, especially for those receiving government subsidies, Marketplace plans often rely on narrower, more restrictive HMO networks. This allows insurers to control costs by negotiating lower rates with a specific set of providers. While PPOs exist on the Marketplace, they are far less common and are often significantly more expensive.
Private Plans Offer More PPOs: The private market caters to a wider range of consumers, including those who do not qualify for subsidies and are willing to pay a higher premium for greater freedom of choice. Therefore, you will find a much broader selection of PPO plans when shopping directly from an insurer or with a broker. This is ideal for people who travel frequently, want to keep their specific doctor who may not be in an HMO, or simply want direct access to specialists.

3. Plan Design and Suitability

Your statement correctly notes that private plans can be particularly helpful for those in good health. This is because many year-round private options are not ACA-compliant.

ACA-Compliant Plans (On or Off the Marketplace): By law, these plans must cover pre-existing conditions and provide 10 Essential Health Benefits (e.g., maternity care, mental health services, prescription drugs). They have no annual or lifetime coverage limits. This comprehensive nature makes them essential for anyone with ongoing health concerns.
Non-ACA-Compliant Private Plans (e.g., Short-Term Medical): These plans are a common alternative found on the private market.
Good for the Healthy: They are medically underwritten, meaning you can be denied based on your health history. Because they don't have to cover the 10 Essential Health Benefits and can exclude pre-existing conditions, their premiums are often much lower. This makes them an attractive, budget-friendly option for healthy individuals who primarily want protection against unforeseen accidents or new illnesses.

The Trade-Off: The lower cost comes with greater financial risk. These plans often have coverage caps, limited prescription drug benefits, and will not cover any treatment related to a condition you had before you enrolled.

All in all, your insurance needs are not the same as the next person's. The best way to find a plan that could help you is to contact an agent and let them know exactly what your looking for. They'll be able to find you plans and mold your benefits into what exactly works for you.

Coverage for pre-existing conditions. (n.d.). HealthCare.gov. Retrieved September 16, 2025, from https://www.healthcare.gov/coverage/pre-existing-conditions/

Glossary. (n.d.). HealthCare.gov. Retrieved September 16, 2025, from https://www.healthcare.gov/glossary/

Open Enrollment Dates. (n.d.). HealthCare.gov. Retrieved September 16, 2025, from https://www.healthcare.gov/quick-guide/dates-and-deadlines/

Robinson, K. M. (2025, July 30). HMO vs. PPO: What’s the Difference? WebMD. Retrieved September 16, 2025, from https://www.webmd.com/health-insurance/hmo-vs-ppo

Author: Quinn Lewis,

Media Manager at American Medical Plans

September News Letter 2025

Mon, 08 Sep 2025 14:47:57 GMT

Bundled Indemnity Plans Explained: Flexibility, Coverage, and Financial Peace of Mind

Discover how bundled indemnity plans can supplement your health insurance, provide financial support for out-of-pocket costs, and give you the freedom to choose any doctor or specialist. Learn if this flexible coverage is right for you.

In today’s complex healthcare landscape, choosing the right health insurance plan can feel like navigating a maze. For many individuals and families, traditional managed care plans — such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs) — may not fully meet their needs. This is where bundled indemnity plans come into play, offering unique benefits that appeal to a variety of situations.

Flexibility and Choice: A Major Selling Point

One of the most compelling features of bundled indemnity plans is the flexibility they offer. Unlike HMOs or PPOs, which restrict patients to a specific network of providers and often require referrals to see specialists, indemnity plans allow policyholders to see virtually any doctor or specialist they choose. This freedom is particularly valuable for people who:

Have a preferred doctor or specialist outside of traditional networks.
Travel frequently and may need access to healthcare in multiple locations.
Live in areas where network options are limited, making specialized care difficult to access.

This level of choice ensures that patients aren’t forced to compromise on the care they want simply because of network restrictions. For many, the ability to see the right provider at the right time can make a significant difference in health outcomes.

Financial Assistance for Out-of-Pocket Costs

Another attractive aspect of indemnity plans is the financial support they provide for medical expenses. These plans offer fixed or predetermined payments for specific services or medical events, regardless of the actual cost or what other insurance covers. This feature can be particularly beneficial for individuals with high-deductible health plans (HDHPs) or those looking to mitigate the unpredictability of medical expenses.

Some key ways indemnity plans help cover costs include:

Offsetting deductibles and co-payments.
Providing coverage for out-of-network care and treatment.
Assisting with hospital-related expenses, including transportation, childcare, and daily living costs during hospital stays.

By providing a financial cushion, indemnity plans help reduce the stress and uncertainty that often accompany healthcare costs.

Bundling Benefits for Convenience

Bundled indemnity plans take coverage a step further by combining multiple types of insurance into one plan. This can include fixed indemnity health plans, short-term health insurance, accident insurance, and critical illness coverage. Consolidating these benefits into a single plan can simplify both administration and payment, making it easier to manage healthcare finances without juggling multiple policies or premiums.

Streamlined Benefits Processing

Many indemnity plans, particularly hospital indemnity plans, are designed with simplicity in mind. They often provide predetermined payouts for specific events, such as a hospital admission or surgery, which can streamline the claims process. This means policyholders can access benefits quickly without navigating complex claims procedures, ensuring timely support when it’s most needed.

Who Might Benefit Most from Bundled Indemnity Plans

While indemnity plans are not a replacement for comprehensive health insurance, they can be particularly useful in certain scenarios:

Individuals with high-deductible health plans looking to cover out-of-pocket costs before primary insurance benefits kick in.
People with chronic conditions requiring frequent hospital visits or specialized care.

These plans provide targeted support, filling gaps that standard health insurance may not cover and offering financial predictability for specific medical events.

Why Buy a Bundled Indemnity Plan?

There are several reasons someone might choose to invest in a bundled indemnity plan:

Supplement Existing Coverage: Indemnity plans are designed to complement, not replace, comprehensive health insurance. They can help cover gaps in coverage or provide additional financial support during medical events.
Budget Certainty: With fixed payments for specific services, indemnity plans allow policyholders to anticipate certain healthcare expenses, reducing uncertainty and improving financial planning.
Freedom of Choice: For individuals who prioritize the ability to select their own doctors and hospitals, indemnity plans offer an attractive alternative to traditional managed care networks.

Considerations and Limitations

While bundled indemnity plans offer unique benefits, it’s essential to understand their limitations. Typically, they do not cover all ten essential health benefits mandated by the Affordable Care Act, and they may exclude coverage for pre-existing conditions. Therefore, they are best considered as a supplement to primary health insurance rather than a standalone solution.

Final Thoughts

In a healthcare environment where flexibility, financial predictability, and choice are increasingly important, bundled indemnity plans provide a compelling option for certain groups of people. By offering targeted financial support, the ability to see any provider, and the convenience of bundled coverage, these plans help individuals manage healthcare costs more effectively.

For anyone seeking supplemental insurance that fills gaps in traditional coverage, supports out-of-pocket expenses, or offers more freedom in choosing providers, bundled indemnity plans deserve a closer look. Understanding how these plans work and evaluating their fit for your specific healthcare needs can empower you to make more informed decisions about your health and financial wellbeing.

Author: Joel Smith

Director of Operations at American Medical Plans

Sources:

HealthCare.gov. (n.d.). Indemnity. Source Link: https://www.healthcare.gov/glossary/indemnity-plan/
Segal, T. (2023, April 2). Indemnity Plan: What It Is, How It Works, Example . Investopedia. Source Link: https://www.investopedia.com/terms/i/indemnity-plan.asp
eHealth. (n.d.). What is an indemnity plan? Source Link: https://www.ehealthinsurance.com/resources/individual-and-family/what-is-an-indemnity-plan

August News Letter 2025

Wed, 20 Aug 2025 15:35:21 GMT

News Letter for August 2025

The Rise of Direct-Pay Healthcare Models

In a healthcare landscape often defined by complex insurance systems and opaque billing practices, a more direct approach known as "cash-pay" or direct-pay healthcare is gaining attention. This model, where patients compensate providers directly without an insurance intermediary, offers a different framework for managing healthcare costs and services. While bypassing insurance may seem counterintuitive, several factors are leading a growing number of individuals to consider this option, particularly as the dynamics of healthcare policy and costs continue to shift.

Key Aspects of Cash-Pay Healthcare

1. Price Transparency A primary characteristic of the cash-pay model is its emphasis on price transparency. In a typical insurance-based transaction, patients may encounter a series of charges—co-pays, deductibles, and other fees—that can obscure the true cost of care until an Explanation of Benefits is received long after a service is provided. The cash-pay model seeks to eliminate this uncertainty. Patients are generally informed of the exact cost of a service upfront, allowing them to make clear, informed financial decisions about their treatment options without the concern of unexpected future bills.

2. Potential for Cost Savings Beyond transparency, direct payment can sometimes result in significant cost savings. This is particularly true for individuals with high-deductible health plans or those without any insurance coverage. For certain procedures, lab tests, or prescriptions, the cash price offered by a provider can be substantially lower than the total amount a patient might pay after navigating the deductibles and cost-sharing requirements of their insurance plan. A study from the Johns Hopkins Bloomberg School of Public Health found that cash prices offered by hospitals were frequently lower than the prices negotiated with insurers, highlighting a market dynamic where direct payment can lead to more favorable rates.

3. Reduced Administrative Load Direct-pay models can significantly simplify the healthcare process by stripping away the administrative layers associated with insurance billing. The conventional system often involves extensive paperwork, pre-authorizations for treatment, and the use of complex billing codes to process claims. A cash-based system can streamline these operations for both parties. For providers, this means less time and resources are spent on administrative tasks, allowing for a greater focus on patient care. For patients, it results in a more straightforward and less cumbersome healthcare experience.

4. Increased Provider Choice and Flexibility Patients who pay for services directly are not constrained by the limitations of an insurance company's provider network. This freedom opens up a wider range of care options, allowing individuals to select doctors, specialists, and services that best align with their specific health needs and personal preferences. This autonomy is especially valuable for those seeking specialized care or wishing to engage with alternative practice models like Direct Primary Care (DPC), where a direct financial relationship with a primary care physician fosters a more personalized and continuous approach to health management.

5. The Patient-Provider Relationship By reducing the administrative burdens placed on providers by insurance companies, the cash-pay model can help foster a stronger patient-provider relationship. When clinicians are not consumed by billing and claims processing, they often have more time to dedicate to each patient. This can lead to more thorough consultations, a deeper understanding of a patient's condition, and a more collaborative treatment plan. The financial transparency and direct interaction inherent in the model can build a foundation of trust and improve communication, enhancing the overall quality of the healthcare experience.

The Affordable Care Act (ACA) and Rising Premiums

The conversation around cash-pay healthcare is increasingly relevant when viewed against the backdrop of the evolving Affordable Care Act (ACA) marketplace. Projections for 2026 indicate a potential for significant increases in ACA premiums, which could present challenges for many enrollees.

A primary driver of this anticipated trend is the scheduled expiration of enhanced premium tax credits at the end of 2025. These subsidies, first expanded by the American Rescue Plan and later extended by the Inflation Reduction Act, have played a crucial role in lowering out-of-pocket premium costs. Policy experts estimate that without a renewal of these credits, the average amount individuals pay for coverage could rise dramatically. This not only impacts affordability for current beneficiaries but also raises concerns that healthier individuals might opt out of coverage, potentially leading to a more costly and less stable insurance pool.

In addition to the expiring subsidies, insurers are requesting median premium increases of around 15% for 2026, citing underlying medical costs, including the use of expensive new drugs. This combination of factors is prompting some consumers to evaluate alternative methods for managing their healthcare expenses. While the cash-pay model is not a universal solution, particularly for catastrophic medical events or complex chronic conditions, its appeal as a transparent and potentially cost-effective option is growing as individuals navigate the increasing financial pressures of traditional insurance plans.

Sources:

Bai, G., Wang, Y., et al. (2023). The Relationships Among Cash Prices, Negotiated Rates, And Chargemaster Prices For Shoppable Hospital Services. Health Affairs, 42(4).

https://pubmed.ncbi.nlm.nih.gov/37011313/

KFF. (2025, August 4). Health Provisions in the 2025 Federal Budget Reconciliation Law.

https://www.kff.org/medicaid/health-provisions-in-the-2025-federal-budget-reconciliation-law/#2ca666ac-5d15-4454-8973-241566e22bb5

Cox, C., et al. (2025, August 6). How Much and Why ACA Marketplace Premiums Are Going Up in 2026. Peterson-KFF Health System Tracker.

https://www.kff.org/affordable-care-act/how-much-and-why-aca-marketplace-premiums-are-going-up-in-2026/

KFF. (2025, August 8). KFF analysis finds a median ACA premium hike of 18% for 2026.

https://www.fiercehealthcare.com/payers/kff-analysis-finds-median-aca-premium-hike-18-2026

U.S. Bureau of Labor Statistics, Inflation Percentages (2025, August 19)

https://www.bls.gov/cpi/

Author: Joel Smith

Director of Operations at American Medical Plans

A Shift Toward Patient Empowerment

Ultimately, the growing interest in cash-pay healthcare reflects a broader desire among consumers for greater clarity, control, and value in their medical care. It is not positioned to replace the insurance system, which remains essential for managing high-cost, unexpected, and chronic health issues. Instead, the direct-pay model is emerging as a valuable component within a more diverse healthcare ecosystem.

As patients become more proactive in managing both their health and their finances, models that prioritize transparency, direct relationships, and administrative simplicity will likely continue to gain traction. The rise of cash-pay is less a rejection of insurance outright and more a signal of a fundamental shift—a move toward a system where empowered patients can make informed choices that best suit their individual needs, creating a more balanced and responsive healthcare landscape for the future.