Health insurance questions, answered

In most states, Open Enrollment for ACA marketplace coverage runs from November 1 through January 15 each year. Plans selected by December 15 typically start January 1; plans selected between December 16 and January 15 typically start February 1. Some state-based exchanges (California, New York, New Jersey, and several others) extend their enrollment windows beyond January 15. Outside of Open Enrollment, you can only enroll if you qualify for a Special Enrollment Period.

A Special Enrollment Period (SEP) is a 60-day window outside of Open Enrollment when you can enroll in or change ACA coverage due to a qualifying life event. Qualifying events include losing other coverage (job loss, COBRA expiration, aging off a parent’s plan), getting married or divorced, having a baby or adopting a child, moving to a new ZIP code with different plan options, becoming a U.S. citizen, or experiencing certain income changes. You generally have 60 days from the event to enroll — proof of the event is usually required.

ACA marketplace plans are sorted into four metal tiers based on how costs are split between you and the plan. Bronze plans cover about 60% of costs (lowest premiums, highest deductibles), Silver covers about 70% (middle ground, eligible for cost-sharing reductions), Gold covers about 80% (higher premiums, lower out-of-pocket), and Platinum covers about 90% (highest premiums, lowest out-of-pocket). The exact networks and providers can differ between plans within the same tier.

The Advance Premium Tax Credit (APTC) is a federal subsidy that lowers your monthly health insurance premium. You qualify if your household income falls within certain limits — currently between 100% and 400% of the federal poverty level, plus expanded eligibility under the Inflation Reduction Act for those above 400% who would otherwise spend more than 8.5% of income on the benchmark plan. The credit is calculated on your estimated annual income and is reconciled at tax time. Underestimating income can mean owing money back; overestimating means a larger refund.

HMO (Health Maintenance Organization) plans require you to choose a primary care physician and get referrals for specialists; out-of-network care isn’t covered except in emergencies. PPO (Preferred Provider Organization) plans let you see any provider in or out of network without referrals, though in-network costs less. EPO (Exclusive Provider Organization) is like an HMO without the referral requirement but with no out-of-network coverage. POS (Point of Service) combines HMO and PPO features — you get a primary care provider and need referrals, but can go out-of-network at a higher cost.

Your deductible is what you pay for covered services before insurance starts paying. A copay is a fixed amount you pay for specific services (e.g., $30 for a doctor visit) — sometimes applied before the deductible is met. Coinsurance is a percentage you pay after the deductible (e.g., 20% of the cost). The out-of-pocket maximum caps your total spending for the year — once you hit it, insurance pays 100% of covered services. In 2026, the ACA out-of-pocket maximum is roughly $9,200 for an individual and $18,400 for a family.

Yes. Under the Affordable Care Act, all ACA marketplace plans must cover pre-existing conditions without charging more or refusing coverage. This protection applies regardless of when the condition was diagnosed or how serious it is. The same protection applies to employer-sponsored plans. Short-term medical plans, however, are not bound by ACA rules and can deny or exclude coverage for pre-existing conditions.

Cost-sharing reductions are extra savings that reduce your deductible, copays, coinsurance, and out-of-pocket maximum. You qualify if your household income is between 100% and 250% of the federal poverty level AND you enroll in a Silver-tier plan through the marketplace. CSRs can dramatically improve plan value: a Silver plan with full CSRs can effectively perform like a Platinum plan for low-income enrollees. Many people don’t realize they qualify and end up choosing a Bronze plan that would have been worse than a CSR-boosted Silver.

Only if your doctor is in the new plan’s network. Before enrolling, look up your doctors, specialists, and any facilities (hospitals, surgery centers) you regularly use in the plan’s provider directory. We do this verification step for every client before recommending a plan — networks change yearly, so even if you’re renewing the same plan name, your doctor’s status can change. Out-of-network care on most ACA plans is either not covered or covered at much higher cost.

An HSA is a tax-advantaged savings account paired with a High Deductible Health Plan (HDHP). You can contribute pre-tax money (up to $4,400 individual or $8,750 family in 2026, plus $1,000 catch-up if 55+) and withdraw it tax-free for qualified medical expenses at any time. Money rolls over year to year — there’s no “use it or lose it.” HSA dollars can also be invested. To contribute, your health plan must be HSA-qualified (specific deductible minimums and no first-dollar coverage for non-preventive care).

You generally can’t enroll in ACA marketplace coverage until the next Open Enrollment unless you qualify for a Special Enrollment Period. If you don’t qualify for an SEP and need coverage immediately, your options include: a short-term medical plan (limited coverage, doesn’t cover pre-existing conditions, not available in all states), Medicaid if you qualify based on income, or staying on an employer plan if one is offered. We can talk through your specific situation to find the best path forward.

Federally, no — the individual mandate penalty was reduced to $0 starting in 2019. However, some states have their own individual mandate with penalties: California, Massachusetts, New Jersey, Rhode Island, and Washington D.C. all penalize residents who go without qualifying coverage. The penalty amounts vary by state. Beyond the financial penalty, going without coverage exposes you to potentially catastrophic medical bills if something unexpected happens.

Premium tax credits are based on the cost of the second-lowest-priced Silver plan in your area (the “benchmark plan”), your household income, and household size. The formula caps what you’re expected to contribute toward the benchmark plan as a percentage of your income, ranging from 0% at the lowest incomes up to 8.5% at higher incomes. The credit then equals the difference between the benchmark plan cost and your expected contribution. You can apply the credit to any metal tier — not just Silver — but the dollar amount of the credit doesn’t change.

No. Our service is completely free. We’re paid by the insurance carriers when you enroll, and our compensation is the same regardless of which carrier you choose — so our recommendations are based on what fits your situation best, not what pays us most. There’s no cost to compare quotes, no obligation to enroll, and we stay with you as your agent for renewals and questions throughout the year.