Health insurance is a simple deal with a big payoff: you pay a set amount every month, and in return your insurance company helps pay your medical bills when you get sick or hurt. You still cover part of the cost yourself through things like deductibles and copays, but the plan shields you from the kind of bills — a surgery, an ER visit, a long hospital stay — that could otherwise wipe out your savings. For Floridians, it also unlocks lower, pre-negotiated rates at a whole network of local doctors and hospitals.
I am Bernie Sobalvarro, an independent health insurance advisor based in Plantation, Florida. I help self-employed folks, families, and small businesses across the state make sense of exactly this. Let me walk you through how it actually works, in plain English.
The basic deal: you pay a premium, the plan shares the cost
Every month you pay a premium — think of it like a membership fee that keeps your coverage active, whether you use it or not. In exchange, when you need care, you and the insurance company split the bill according to your plan's rules. The trick is understanding how that split works, because that is where most of the confusion, and most of the surprise bills, come from.
The four words that trip everyone up
Deductible. This is what you pay out of pocket before the plan really kicks in. If your deductible is $3,000, you cover the first $3,000 of covered care each year, then the plan starts paying its share.
Copay. A flat fee for a specific service — say $30 to see your doctor or $15 for a prescription. Many plans let you pay copays for everyday visits even before you have hit your deductible.
Coinsurance. After your deductible, you and the plan split costs by percentage. An 80/20 plan means the insurer pays 80% and you pay 20% until you reach your out-of-pocket max.
Out-of-pocket maximum. This is your safety net — the most you will pay in a year. Once you hit it, the plan covers 100% of covered care for the rest of the year. For 2026 ACA plans this cap is set by law, so you always know your worst-case number.
How a real claim actually works
Here is a real example (name changed). Maria, a self-employed graphic designer in Fort Lauderdale, came to me with a private PPO plan that had a $2,500 deductible and an 80/20 split. She slipped, broke her wrist, and the ER plus follow-up care came to about $9,000.
She paid the first $2,500 — her deductible. On the remaining $6,500 she paid 20%, which was $1,300, and the plan paid the rest. Her total came to roughly $3,800 instead of $9,000, and because that pushed her toward her out-of-pocket max, the rest of her care that year was fully covered. Without insurance, that $9,000 bill would have been hers alone. That is the whole point of coverage: it turns a scary, unpredictable bill into a manageable, capped one.
What health insurance covers
Under the Affordable Care Act, every major medical plan sold in Florida has to cover a set of essential health benefits — doctor visits, hospital stays, emergency care, prescription drugs, maternity care, mental health, lab work, and free preventive care like annual checkups and screenings. Preventive visits are typically covered at 100%, even before you meet your deductible, which is why I always tell clients not to skip their yearly physical.
Where Floridians get their coverage
Most people in Florida get health insurance one of four ways: through a job, through the ACA marketplace (where income-based subsidies can dramatically lower your premium), through a private PPO plan, or through a small-business group plan. If you are an individual or family, the marketplace and private plans are usually where we start. If you run a company, a small-business group plan may make more sense. Because I am independent, I can compare across all of them and find the one that actually fits your budget and your doctors.
Frequently asked questions
Do I have to use my insurance to get value from it? No. Even if you never file a claim, you are paying for protection against a catastrophic bill — and you still get free preventive care and network discounts.
What if I want to keep my current doctor? Tell me before you enroll. Each plan has its own network, and I will check that your doctors and preferred hospitals are in-network before you sign up.
Is the cheapest plan the best plan? Not always. A low premium often means a high deductible. The right plan balances the monthly cost against what you would actually pay if you got sick. I break this down in how much you should pay for health insurance per month.
Let's find the right plan for you
Health insurance does not have to be confusing — that is my job. I will explain your options in plain English and handle the paperwork. Book a free quote here or call me directly at (305) 900-5903, and we will find coverage that fits your life and your budget.
