How Americans get health coverage
Most people in the US are covered through an employer plan, a government program such as Medicare, Medicaid or CHIP, or an individual plan bought through the Health Insurance Marketplace at HealthCare.gov or a state-run exchange. The federal penalty for going without coverage was reduced to zero starting in 2019, but California, Massachusetts, New Jersey, Rhode Island and the District of Columbia have their own requirements with state tax penalties.
What Marketplace plans cover
Plans sold on the Marketplace must cover ten categories of essential health benefits: outpatient care, emergency services, hospitalization, pregnancy and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services, laboratory services, preventive and wellness care with chronic disease management, and pediatric services including dental and vision care for children. According to HealthCare.gov, these plans cannot reject you, charge you more or refuse to cover treatment because of a pre-existing condition. Grandfathered individual plans are an exception.
Metal tiers and plan types
Marketplace plans are grouped by how costs are split. HealthCare.gov estimates the plan's share at about 60 percent for Bronze, 70 percent for Silver, 80 percent for Gold and 90 percent for Platinum, with you paying the rest through deductibles, copays and coinsurance. Catastrophic plans are available to people under 30 and to some who qualify for a hardship exemption. Networks matter as much as tiers:
- HMO plans usually require you to use in-network providers and get referrals for specialists.
- PPO plans let you see out-of-network providers at a higher cost.
- EPO plans cover in-network care only, except emergencies, but often without referrals.
- POS plans combine a primary care doctor with some out-of-network coverage.
Key cost terms
The premium is what you pay each month. The deductible is what you pay for covered services before the plan starts sharing costs. A copay is a flat fee per service, and coinsurance is your percentage share. The out-of-pocket maximum caps what you pay for covered in-network care in a plan year. A low premium with a high deductible can cost more overall if you use a lot of care. Some high-deductible plans qualify you for a health savings account (HSA), which lets you set aside pre-tax money for medical expenses.
When you can enroll
Individual coverage is bought during the annual Open Enrollment Period, which starts November 1 on HealthCare.gov; state exchanges may set different deadlines. Outside that window you need a Special Enrollment Period triggered by a life event such as losing job-based coverage, moving, marriage or having a baby, and you generally have 60 days to enroll. Medicaid and CHIP accept applications year-round. Short-term plans do not have to follow these Marketplace rules and often exclude pre-existing conditions.
How to choose a plan
List the doctors, hospitals and prescriptions you rely on and confirm each is in the plan's network and formulary. Compare total annual cost, not just the premium, and check whether you qualify for premium tax credits based on household income. If you expect frequent care, a Gold or Silver plan may cost less overall than Bronze. Our health insurance calculator helps compare premiums with likely out-of-pocket costs.
Claims, bills and appeals
In-network providers bill the plan directly; you receive an Explanation of Benefits showing what was paid and what you owe. Review bills against it. If a claim or prior authorization is denied, the Affordable Care Act gives you the right to an internal appeal with the insurer and, in many cases, an external review by an independent reviewer.
Polis Re helps you compare individual and family health plan options and request quotes in one place. Policies are issued by licensed insurers and placed through licensed producers in your state.
