ACA Knowledge Guide

The ACA is a federal law from 2010 that made it illegal for insurance companies to deny you coverage because of a health condition, and created a marketplace where you can shop for health insurance and possibly get financial help to pay for it.

The Affordable Care Act (ACA), signed into law in March 2010, is the federal health reform law that established consumer protections, created the Health Insurance Marketplace, expanded Medicaid, and introduced financial assistance for eligible individuals and families.

Marketplace insurance is health coverage you can shop for and buy at HealthCare.gov or your state's exchange website. Depending on your income, you may qualify for financial help that makes it much more affordable.

Marketplace health insurance is ACA-compliant coverage sold through HealthCare.gov (for most states) or a state-based exchange, where eligible applicants can compare plans, enroll, and apply for premium tax credits or cost-sharing reductions.

Marketplace coverage is for people who need to buy their own health insurance—like those who are self-employed, between jobs, or whose job doesn't offer affordable coverage.

ACA Marketplace coverage is designed for U.S. citizens, nationals, and lawfully present immigrants who are not incarcerated, are not eligible for government-sponsored coverage like Medicare or Medicaid, and need individual or family health insurance.

An ACA-compliant plan follows the rules the law set for health insurance—it has to cover essential services, can't turn you away for health reasons, and can't charge you unlimited amounts out of pocket.

ACA-compliant coverage is a health plan that meets all federal requirements under the Affordable Care Act, including covering the 10 essential health benefits, following community rating rules, and complying with consumer protections like guaranteed issue and no pre-existing condition exclusions.

ACA plans must cover your pre-existing conditions and all major medical services. Short-term plans are cheaper but can deny you coverage, exclude your health conditions, and leave you with large unexpected bills.

ACA coverage must cover all 10 essential health benefits, cannot exclude pre-existing conditions, and has no lifetime dollar limits; short-term insurance can deny enrollment based on health, exclude pre-existing conditions, skip essential benefits, and leave enrollees with uncapped out-of-pocket costs.

Anyone who lives in the U.S., is a citizen or legally present immigrant, and isn't on Medicare can apply for Marketplace coverage—even if your income is low or high.

U.S. citizens and nationals, and lawfully present immigrants who live in the Marketplace service area, are not incarcerated, and are not enrolled in Medicare can apply for Marketplace coverage.

You don't have to be a citizen to enroll. Legal immigrants with valid immigration status can buy Marketplace coverage. Undocumented immigrants cannot.

No—U.S. citizenship is not required. U.S. citizens, nationals, and lawfully present immigrants are all eligible to apply for Marketplace coverage. Undocumented immigrants are not eligible.

Yes, most legal immigrants can sign up for Marketplace health coverage and may qualify for financial help. You'll need to provide documents proving your immigration status.

Yes. Lawfully present immigrants—including green card holders, refugees, asylees, TPS holders, and valid visa holders—can enroll in Marketplace plans. They may also qualify for premium tax credits and cost-sharing reductions.

Yes—you must live in the state where you're applying. Each Marketplace is state-specific, so you can only buy a plan that covers where you live.

Yes. You must live in the state where you apply and purchase Marketplace coverage. You cannot enroll in a plan from another state, and you must reside within the plan's service area.

Yes, moving to a new area gives you 60 days to sign up for a health plan. You don't have to wait for open enrollment—your move is your qualifying reason to enroll.

Yes. A permanent move to a new coverage area triggers a Special Enrollment Period, giving you 60 days to enroll in a Marketplace plan in your new location.

Open Enrollment is the annual window to sign up for health insurance. For 2026 plans, it was November 1 through mid-January. If you enroll by December 15, your coverage starts January 1.

Open Enrollment is the annual window during which anyone eligible for Marketplace coverage can enroll in or change plans for the next coverage year. For 2026 coverage, the Open Enrollment Period was November 1–January 15, 2026, on HealthCare.gov.

You can enroll during Open Enrollment each fall/winter, or at any time if something big happens in your life—like losing your job-based coverage or getting married.

You can enroll in a Marketplace plan during the annual Open Enrollment Period (November–January for federal Marketplace), or outside OEP if you have a qualifying life event that triggers a Special Enrollment Period.

Yes, if something major happens in your life—like losing your health insurance, moving, or having a baby—you get a 60-day window to sign up for a Marketplace plan even when it's not open enrollment season.

Yes, you can enroll outside Open Enrollment if you have a qualifying life event that triggers a Special Enrollment Period. Without a qualifying event, you must wait for the next Open Enrollment Period.

An SEP is your window to sign up for health insurance after something big changes in your life. It usually lasts 60 days from the day the qualifying event happened.

A Special Enrollment Period (SEP) is a limited time window—typically 60 days—to enroll in or change Marketplace coverage outside of Open Enrollment, triggered by a qualifying life event such as losing coverage, getting married, or having a baby.

You have 60 days from your qualifying event to sign up. If you lost Medicaid, you get 90 days. Don't wait too long—if you miss the window, you may have to wait until next open enrollment.

Generally 60 days from the qualifying life event—either to enroll or make a plan change. For loss of Medicaid or CHIP, the SEP window is 90 days. You can also start some SEPs up to 60 days before a qualifying event.

You can apply online at HealthCare.gov (or your state's exchange site), by phone, or with help from a free licensed agent or local enrollment counselor.

You can apply for ACA Marketplace coverage at HealthCare.gov (for most states), at your state's exchange website, by phone (1-800-318-2596), or with the help of a licensed agent, broker, or navigator.

The application asks who's in your family, everyone's income, your Social Security numbers, and whether anyone is offered health insurance at work. Gathering this information before you start will make it faster.

The application asks for: Social Security numbers (or immigration document numbers), dates of birth, citizenship/immigration status, household members and their relationship to you, projected annual income for all household members, and information about any other health coverage available.

Yes, you need Social Security numbers for anyone in your household who is applying for coverage and is a U.S. citizen. If a family member is an immigrant, they use their immigration document number instead.

You need Social Security numbers for all household members who are applying for coverage and who are U.S. citizens or nationals. Lawfully present immigrants without SSNs provide immigration document numbers instead.

Yes—you can apply online yourself, call the Marketplace directly, or work with a free local helper or licensed insurance agent. All of these are valid ways to get enrolled.

Yes. You can apply online at HealthCare.gov or your state Marketplace website, by calling the Marketplace call center (1-800-318-2596), or with in-person help from a licensed agent, broker, or free navigator/enrollment assister.

Everyone in your tax household should be listed, even if some people already have coverage or don't want to enroll. Their income counts toward your household total, which affects how much financial help you qualify for.

You must list all members of your tax household on the application—including tax dependents—even if some will not be enrolling in a Marketplace plan. Their income and eligibility affects your subsidy calculation.

The premium tax credit is a government subsidy that reduces your monthly health insurance bill. In 2026, it's only available if your household income is between about $15,960 and $62,600 for a single person.

The premium tax credit (PTC) is a federal tax credit that helps eligible people and families pay for health insurance purchased through the Marketplace. For 2026, it is available only to households with income between 100% and 400% FPL.

In 2026, you can only get a subsidy if your income is between about $15,960 and $62,600 (single person), you buy insurance through the Marketplace, and you don't have access to affordable job-based or government health insurance.

To qualify for the 2026 premium tax credit, a household must: (1) have income between 100%–400% FPL, (2) enroll in a Marketplace plan, (3) not be eligible for affordable employer coverage or government programs like Medicaid or Medicare, and (4) file a joint return if married.

The Marketplace calculates the gap between the cost of the standard Silver plan and what you're expected to pay based on your income. That gap becomes your monthly subsidy, which is sent directly to your insurance company.

The premium tax credit lowers your monthly premium by calculating the difference between the benchmark plan cost and your required contribution percentage. The credit is applied directly to your insurer each month when taken as APTC.

Yes, you can take a smaller subsidy each month or skip monthly payments altogether and claim the credit at tax time. This can protect you from having to pay money back if your income turns out to be higher than you expected.

Yes. You can choose to receive less advance premium tax credit than you qualify for—or none at all—and claim the remainder when you file your taxes. This reduces repayment risk if your income ends up higher than estimated.

Yes, you can take the full subsidy monthly so you pay less each month. Just be aware that if your income ends up being higher than you reported, you'll need to pay some of it back when you do your taxes.

Yes. You can elect to have your full calculated advance premium tax credit applied each month to reduce your monthly premium. The full credit is paid to your insurer monthly; you reconcile the actual amount on your tax return.

A cost-sharing reduction (CSR) is extra government help that reduces what you pay when you actually use your health insurance—like your deductible and copays. You have to pick a Silver plan through the Marketplace to get this benefit.

A cost-sharing reduction (CSR) is a federal benefit that reduces the deductibles, copays, coinsurance, and out-of-pocket maximums for eligible Marketplace enrollees. CSRs are only available on Silver plans purchased through the Marketplace.

In 2026, you qualify for CSRs if your income is between about $15,960 and $39,900 (single person), you pick a Silver plan on the Marketplace, and you're not eligible for Medicaid or affordable job-based insurance.

To qualify for cost-sharing reductions in 2026, you must: (1) have household income between 100% and 250% FPL, (2) enroll in a Silver plan through the official Marketplace, and (3) be eligible for premium tax credits.

No—CSRs only work if you pick a Silver plan through the Marketplace. If you choose any other plan type, you won't get the extra help with your deductibles and copays even if your income qualifies.

No. Cost-sharing reductions only work on Silver plans purchased through the Marketplace. Choosing Bronze, Gold, Platinum, or Catastrophic plans—even through the Marketplace—makes you ineligible for CSRs, regardless of income.

The law was designed so Silver plans serve as the standard reference point for both subsidies and extra cost-sharing help. It's the 'middle' metal level that's meant to be the standard choice for most people getting financial help.

CSRs are tied to Silver plans by statute. Congress designed the ACA so that Silver plans serve as the benchmark for subsidy calculations AND the vehicle for cost-sharing reductions, creating a consistent 'middle tier' that balances premiums and cost-sharing.

CSRs dramatically lower your costs when you use care—like your deductible, copays, and the most you'll pay in a year. For people with income below 150% of the poverty level, the Silver plan can work almost like Platinum coverage, but at a much lower cost.

CSRs increase the actuarial value of Silver plans, which directly lowers deductibles, copayments, and coinsurance amounts. The specific dollar reductions vary by plan and carrier, but CSR Silver plans are required to hit specific AV targets.

The Marketplace counts most types of income — wages, self-employment, Social Security, unemployment, and investment income — but not child support or SSI. You must report your best estimate of this year's total household income.

For ACA subsidies, income means Modified Adjusted Gross Income (MAGI) — essentially your adjusted gross income plus certain add-backs like tax-exempt interest and non-taxable Social Security benefits.

Your 'household' for health insurance purposes is the same group of people you put on your tax return — you, your spouse, and any dependents you claim.

For Marketplace purposes, 'household' means the people you list on your federal tax return — yourself, your spouse if filing jointly, and anyone you claim as a tax dependent.

The Marketplace subsidizes your premium based on your estimated income. At tax time, the IRS checks whether the subsidy matched your real income — if you made more than expected, you may owe some money back.

The Marketplace asks about tax filing because premium tax credits are reconciled on your federal tax return — the subsidy you receive during the year must match what your actual annual income supports.

MAGI is basically your taxable income plus a few extras the IRS normally lets you exclude — mainly non-taxable Social Security and tax-free interest. It's the income number the Marketplace uses to decide your subsidy.

Modified Adjusted Gross Income (MAGI) for ACA purposes is your IRS Adjusted Gross Income (AGI) plus tax-exempt interest, non-taxable Social Security benefits, and excluded foreign income.

Yes — Social Security retirement and disability benefits count as income for ACA purposes. SSI (Supplemental Security Income) does not count.

Yes, Social Security income generally counts toward MAGI for ACA subsidies. The taxable portion of Social Security always counts, and the non-taxable portion is added back into MAGI.

When you apply on the Marketplace, it automatically checks whether you qualify for Medicaid or CHIP. If you do, it sends your application to the state Medicaid office. Some family members may get Medicaid while others get Marketplace coverage.

When you apply through the Marketplace, it automatically screens your household for Medicaid and CHIP eligibility and routes eligible members to those programs instead of — or alongside — Marketplace plans.

CHIP covers kids from families who make too much for Medicaid but need help with costs. The Marketplace screens for CHIP automatically. Parents can still get their own Marketplace plan while kids are on CHIP.

The Marketplace screens children for CHIP eligibility. Children who qualify for CHIP are directed there rather than to Marketplace plans. Adults who apply can still get Marketplace coverage independently.

Yes — if the Marketplace thinks you qualify for Medicaid based on your income, it automatically sends your application to the state Medicaid office. You don't have to apply separately.

Yes. When you apply through the Marketplace, it determines whether you appear eligible for Medicaid based on your income and household information, then sends your case to the state Medicaid agency for final enrollment.

Yes, this is common. Your child can be on CHIP while you use a Marketplace plan. Each family member can be on a different program based on their own eligibility.

Yes, your child can qualify for CHIP while you do not qualify for Medicaid and instead enroll in a Marketplace plan. This is a common 'split-benefit' household situation.

Absolutely yes. In the same family, one parent might be on Medicaid, the kids on CHIP, and the other parent on a Marketplace plan. That's completely normal and the Marketplace is designed to handle it.

Yes, it is common for different family members to be covered by different programs — some on Medicaid, some on CHIP, and others on Marketplace plans — based on each person's individual eligibility.

Yes, you can always buy a Marketplace plan. But to get a subsidy, your employer's plan must be either too expensive (over 9.96% of your income in 2026) or cover too little (less than 60% of costs).

Yes, you can buy a Marketplace plan even if your employer offers coverage. However, you can only receive premium tax credits if the employer's plan fails the affordability or minimum value tests.

You can get subsidies only if your employer's plan costs you more than 9.96% of your household income (for 2026), or if the plan is skimpy and covers less than 60% of costs. Otherwise, no subsidy is available.

You can only get Marketplace subsidies if your employer's plan is either unaffordable (employee share exceeds 9.96% of income in 2026) or fails to provide minimum value (covers less than 60% of costs).

For 2026, your employer's plan is 'affordable' if what you pay for just your own coverage is less than 9.96% of your income. There's also a simple dollar-amount test: if you pay $129.89/month or less for self-only, it's always considered affordable.

Employer coverage is 'affordable' for 2026 if the employee's required contribution for self-only coverage does not exceed 9.96% of household income. The FPL safe harbor amount is $129.89/month.

An employer plan meets 'minimum value' if it pays at least 60% of your average medical costs — similar to a Bronze plan. Most normal employer plans pass this test easily. Very skimpy plans may fail.

Minimum value means the employer's health plan pays at least 60% of the total allowed costs of benefits provided under the plan — equivalent to a Bronze plan's 60% actuarial value threshold.

Yes — since 2023, the 'family glitch' has been fixed. If adding your family to your employer's plan costs more than 9.96% of your household income, your family can get Marketplace subsidies even if your own coverage is affordable.

Yes — following the 2023 'family glitch fix,' dependents can qualify for Marketplace subsidies if the cost of family coverage (not just self-only coverage) is unaffordable, even if the employee's self-only offer passes the affordability test.

Many immigrants who are here legally can use the Marketplace — green card holders, refugees, asylum seekers, TPS holders, and many visa holders all qualify. DACA recipients cannot enroll as of August 25, 2025. Undocumented immigrants cannot enroll.

Yes, many lawfully present immigrants can enroll in Marketplace health plans. Eligible categories include lawful permanent residents, refugees, asylees, TPS holders, visa holders, and others with valid lawful presence documentation.

No — undocumented immigrants cannot buy Marketplace plans or get subsidies. Their U.S. citizen children can get coverage. Emergency Medicaid is available for genuine emergencies. Community health centers serve everyone regardless of status.

No. Undocumented immigrants (those without lawful immigration status) cannot enroll in Marketplace health plans or receive premium tax credits. They also cannot enroll in Medicaid for non-emergency services.

Yes — in a mixed-status family, the members who are lawfully present or U.S. citizens can apply for Marketplace coverage. Undocumented members don't need to be included in the application. The Marketplace does not report information to immigration enforcement.

Yes. Mixed-status families — where some members are lawfully present or U.S. citizens and others are undocumented — can apply for Marketplace coverage for the eligible members only.

Yes — U.S. citizen children can get Marketplace coverage, Medicaid, or CHIP based on their own citizenship and your family's income. The parents' immigration status doesn't affect the child's eligibility.

Yes. U.S. citizen children can enroll in Marketplace plans, Medicaid, or CHIP based on their own citizenship status and household income, regardless of their parents' immigration status.

The Marketplace may ask to see your immigration paperwork to confirm you're lawfully present. A green card, work permit, refugee document, or valid visa with I-94 are commonly accepted. Have your documents ready when applying.

The Marketplace may request immigration documents to verify lawful presence. Common documents include permanent resident cards (green cards), Employment Authorization Documents (EADs), refugee admission documents, asylee approval notices, TPS approval notices, and valid non-immigrant visas with I-94.

The metal level tells you how costs are split between you and your insurance company. Bronze means you pay more when you use care but less per month. Platinum means you pay less when you use care but more per month. Silver is the middle ground — and the only level where you can get extra cost savings if your income qualifies.

Bronze, Silver, Gold, and Platinum are ACA 'metal levels' — they represent how costs are split between you and the plan. Bronze covers about 60% of average costs; Silver 70%; Gold 80%; Platinum 90%.

Higher metal = higher monthly premium but lower bills when you go to the doctor. Lower metal = lower monthly premium but you pay more each time you use care. Everyone hits the same maximum out-of-pocket cap once costs add up.

Higher metal levels (Gold, Platinum) mean lower out-of-pocket costs when you receive care — smaller deductibles, lower copays, and lower coinsurance. Lower metal levels (Bronze) mean higher out-of-pocket costs but lower monthly premiums.

Bronze plans have the lowest monthly premiums — but you'll pay more when you actually use healthcare. If you're eligible for a subsidy, your net cost after the subsidy can make Silver or Gold plans equally affordable on a monthly basis.

Bronze plans have the lowest monthly premiums of the four standard metal levels. Catastrophic plans have even lower premiums but are only available to people under 30 or with a specific exemption.

Platinum plans almost always have the lowest deductibles — sometimes zero. Bronze plans have the highest deductibles, which means you pay the full cost for most services until you meet that high amount. Preventive care is always free regardless of deductible.

Platinum plans typically have the lowest deductibles — often $0 or very low amounts — because they have the highest actuarial value (~90%). Gold plans also have low deductibles. Bronze plans generally have the highest deductibles.

Yes — all Marketplace plans cover the same basic set of health services no matter which metal level. The difference is how much you pay for those services, not whether they're covered at all.

Yes — all ACA Marketplace plans at every metal level must cover the same 10 Essential Health Benefits. What differs between metal levels is how much the plan pays vs. how much you pay, not what services are covered.

Your plan's network is the list of doctors and hospitals that your insurance company has an agreement with. Use providers on that list to pay the lowest amounts. If you go outside the list, you'll pay a lot more — or possibly the full cost.

ACA plan provider networks are the set of doctors, hospitals, and other providers that have contracted with the insurer to provide care at negotiated rates. Using in-network providers results in lower cost-sharing; going out-of-network usually costs significantly more or is not covered at all.

HMO: cheapest, but you need your primary doctor to refer you everywhere, and no out-of-state coverage. PPO: most flexible, you can see any doctor anywhere, but it costs more. EPO: like PPO for ease but no coverage outside the network. POS: a blend of HMO and PPO.

HMO requires using a primary care physician and getting referrals to see specialists; PPO allows self-referrals with both in- and out-of-network coverage; EPO requires in-network use only (no out-of-network coverage except emergencies) with no referrals; POS combines HMO's PCP gatekeeper with PPO's out-of-network option.

Don't assume your doctor is covered just because they work with that insurance company. Each plan has its own network — always look up your doctor in the specific plan you're considering before enrolling, and call the doctor's office to double-check.

Not necessarily. You must check whether your specific doctor participates in the specific plan you're considering — not just whether they accept the insurer's other plans or the same metal level from that carrier. Always verify directly with the plan's provider directory or call the carrier.

Check the insurance company's website or the plan details on HealthCare.gov to find the doctor search tool for that specific plan. Then call the doctor's office and double-check. Don't skip the call — online directories can be out of date.

To verify whether a provider is in-network, use the plan's official online provider directory (accessed through the carrier's website or HealthCare.gov plan details), and then confirm by calling the doctor's office or the insurance carrier directly.

If you see a doctor or go to a hospital that's not in your plan's network, you'll pay much more — and for some plan types (HMO, EPO), the insurance won't cover it at all unless it's a true emergency. Emergency care is always covered at in-network rates regardless of where you go.

Going out-of-network means you'll pay significantly more — or possibly 100% of the cost. On HMO/EPO plans, non-emergency out-of-network care is usually not covered at all. On PPO/POS plans, out-of-network care is covered but with higher deductibles and coinsurance.

Every ACA plan must cover prescription drugs, but each plan has its own list of covered drugs (called a formulary), so the same medication could cost very different amounts depending on which plan you choose.

Yes, prescription drugs are an Essential Health Benefit (EHB) that all ACA Marketplace plans must cover, though each plan's formulary — its list of covered drugs — differs by insurer and metal level.

A formulary is a list of drugs your insurance plan covers. Drugs are grouped into tiers — the lower the tier, the less you pay. If your drug is not on the list, you may have to pay full price or request an exception.

A formulary is a plan's official list of covered prescription drugs, organized into tiers that determine how much you pay for each drug.

Go to HealthCare.gov or the insurance company's website and use their drug search tool. Type in your medication name to see if it's covered, what tier it's on, and what you'll pay.

Use the plan's drug formulary search tool on HealthCare.gov or the insurer's website; enter your medication name and confirm its tier, cost-sharing, and any utilization management requirements before enrolling.

No — every plan must cover some prescription drugs, but each plan's list (formulary) is different. A drug covered cheaply on one plan could be very expensive or not covered at all on another.

No. While all ACA plans must cover prescription drugs as an EHB, each plan has its own formulary, so the same drug may be covered differently — on a different tier or not covered at all — depending on the plan.

Prior authorization means your doctor must get the insurance company's approval before they'll pay for a drug. Without that approval, you may have to pay full price.

Prior authorization (PA) is a requirement that your doctor obtain approval from the insurance plan before the plan will cover a specific drug or service.

EHBs are 10 categories of care — like hospital stays, prescriptions, and mental health treatment — that every ACA plan must cover. Every plan must have all 10, though the specific services within each category can vary.

Essential Health Benefits (EHBs) are 10 categories of services that all ACA Marketplace and most individual and small-group plans must cover: ambulatory care, emergency, hospitalization, maternity/newborn, mental health/SUD, prescription drugs, rehab/habilitative, lab, preventive/wellness, and pediatric (including oral and vision).

Yes. ACA plans must cover many preventive services — like annual physicals, mammograms, vaccines, and colorectal cancer screening — for free, with no copay and no deductible, as long as you use an in-network provider.

Yes. ACA plans must cover preventive services rated 'A' or 'B' by the USPSTF, ACIP-recommended vaccines, and women's preventive services with no cost-sharing — no copay, no deductible.

Free preventive care includes annual physicals, vaccines, cancer screenings (like colonoscopies and mammograms), cholesterol checks, depression screening, and birth control for women — all at no charge when done in-network.

Covered preventive services with no cost-sharing include blood pressure and cholesterol screening, colorectal cancer screening (colonoscopy, stool tests), mammograms, Pap smears, routine vaccines, depression screening, obesity counseling, tobacco cessation, and contraception for women.

Yes. All ACA plans must cover maternity care, including prenatal visits, labor and delivery, and care for the newborn. You'll still have copays and deductibles, but the coverage must be there.

Yes. Maternity and newborn care is one of the 10 EHB categories, so all ACA Marketplace plans must cover prenatal visits, labor and delivery, and newborn care.

Yes. All ACA plans must cover mental health services and addiction treatment. Under federal parity law, your plan can't make mental health care harder to access than physical health care.

Yes. Mental health and substance use disorder (MH/SUD) services are one of the 10 EHBs, and the Mental Health Parity and Addiction Equity Act (MHPAEA) requires plans to cover them at parity with medical/surgical benefits.

Don't just look at the monthly premium. Also check the deductible (what you pay before insurance kicks in), the copays for doctor visits and drugs, and the out-of-pocket maximum (the most you'd ever pay in a year — $10,600 for one person in 2026).

Beyond the monthly premium, evaluate the deductible, copays and coinsurance for specific services, the out-of-pocket maximum, and whether your doctors, hospitals, and drugs are in-network — these often matter more than the premium for people who use healthcare regularly.

The deductible is the amount you pay yourself for medical care before your insurance starts paying. If your deductible is $2,000, you pay the first $2,000 of medical bills each year. After that, your insurance kicks in.

The deductible is the dollar amount you must pay for covered services each plan year before your insurance begins paying its share. For 2026, individual deductibles on ACA Marketplace plans can range from $0 to several thousand dollars depending on the metal level and plan design.

A copay is a fixed fee you pay when you use a service — like $35 for a doctor visit or $15 for a generic medication. You pay the same amount regardless of the total bill.

A copay is a fixed dollar amount you pay for a specific covered service at the time of service — for example, $35 for a primary care visit or $20 for a generic prescription — regardless of the total cost of the service.

Coinsurance is your share of a medical bill, expressed as a percentage. If your coinsurance is 20%, you pay 20% of the insurance company's negotiated rate for the service — after you've already met your deductible.

Coinsurance is your percentage share of the cost of a covered service after you have met your deductible. For example, 20% coinsurance means you pay 20% of the allowed amount and the plan pays 80%.

The out-of-pocket maximum is your financial safety net — the most you'll ever pay for covered in-network care in a year. In 2026, that cap is $10,600 for one person and $21,200 for a family. After that, your insurance pays 100%.

The out-of-pocket maximum is the most you will pay for covered, in-network essential health benefits in a plan year. For 2026, the federal OOP maximums are $10,600 for individual coverage and $21,200 for family coverage — no ACA plan can exceed these amounts.

You can sign up for ACA coverage outside of Open Enrollment if something big happens in your life — like losing job-based insurance, getting married, having a baby, or moving to a new area. You usually have 60 days from that event to enroll.

Qualifying life events for an SEP include loss of minimum essential coverage, marriage, birth/adoption/foster placement, permanent move to a new coverage area, gaining lawful immigration status, loss of Medicaid/CHIP, and certain other events. SEPs generally last 60 days from the qualifying event.

Yes. If you lose your health insurance — like when you leave a job, get laid off, or turn 26 and come off your parents' plan — you have 60 days to sign up for a new Marketplace plan. Act quickly so there's no gap in coverage.

Yes. Losing minimum essential coverage (MEC) involuntarily — such as when job-based insurance ends, COBRA expires, or a plan is discontinued — triggers a 60-day SEP to enroll in Marketplace coverage.

Yes. If you move to a new city, county, or state, you have 60 days to pick a new ACA plan in your new area. You'll need to prove the new address with a document like a utility bill or lease.

Yes. A permanent move to a new county, ZIP code, or state that makes new Marketplace plans available triggers a 60-day SEP, even if you already have coverage — provided you had coverage before the move (or recently gained it).

Yes. Getting married is a qualifying event that gives you 60 days to change or get new health coverage. You'll need to show your marriage certificate and may need to update your income information since your household will now be combined.

Yes. Getting married triggers a 60-day SEP. Both spouses can enroll in or change Marketplace plans, and the new household size and income are used to calculate subsidy eligibility.

Divorce qualifies for an SEP mainly if you lose your health coverage as a result — like if you were on your ex-spouse's insurance. If the divorce didn't change your coverage, you may not automatically get an SEP on the federal Marketplace, but state Marketplaces may differ.

Yes, but only if the divorce results in loss of health coverage — divorce alone (without a coverage loss) may not trigger an SEP on the federal Marketplace, though some state-based Marketplaces recognize divorce as a standalone qualifying event.

Form 1095-A is a tax form from the health insurance Marketplace. It shows how much subsidy was paid on your behalf each month. You need this form to complete your federal taxes if you got a subsidy.

Form 1095-A is the Health Insurance Marketplace Statement sent by the Marketplace to enrollees who had Marketplace coverage. It shows the months covered, the premium for the second-lowest-cost Silver plan (SLCSP), and the amount of advance premium tax credits (APTC) paid on your behalf.

Anyone who bought health insurance through the Marketplace — HealthCare.gov or a state Marketplace — gets a 1095-A, whether or not they got a subsidy. Multiple forms are sent if you had more than one plan during the year.

Every person or household that had health coverage through a Marketplace (HealthCare.gov or a state-based Marketplace) during the year receives a Form 1095-A, regardless of whether they received advance premium tax credits.

Form 8962 is the IRS form you fill out at tax time to settle up your health insurance subsidy. It compares what the government already paid toward your premiums with what you were actually entitled to based on your real income.

Form 8962 (Premium Tax Credit) is the IRS form used to calculate the actual premium tax credit you are entitled to based on your final household income and family size, and to reconcile it against any APTC paid in advance during the year.

The government pays your health insurance subsidy each month based on your estimated income. At tax time, you compare that estimate to your real income. If you earned more than expected, you pay some back. If you earned less, you get a refund.

Marketplace subsidies are paid as advance premium tax credits (APTC) based on estimated income. At tax time, your actual income is compared to your estimate, and Form 8962 is used to settle the difference — paying back any excess or claiming any additional credit owed.

If you got more subsidy than you were entitled to based on your real income, you have to pay some back at tax time. There are limits on how much you have to repay if your income is moderate, but if your income was very high, you could owe the full amount back.

If you received more APTC than your actual income entitles you to, you must repay the excess as additional tax on Form 8962. The repayment is capped for households with income between 100%–400% FPL; above 400% FPL, all excess APTC must be repaid.

Tell the Marketplace whenever your family size, income, or health coverage changes — even mid-year — so your financial help stays accurate and you don't owe money at tax time.

You should report any change to household size, income, or coverage status to the Marketplace as soon as possible, since these changes can affect your premium tax credit, cost-sharing reductions, and plan eligibility.

If your income goes up and you don't report it, you could face a surprise tax bill. If it drops, you may be paying too much for your plan. Updating your income mid-year fixes both problems.

Reporting income changes quickly keeps your advance premium tax credit (APTC) accurate — if your income rises and you delay reporting, you may have to repay excess APTC when you file taxes; if it drops, you could be getting less help than you're entitled to.

Tell the Marketplace about your new job — especially if your employer offers health insurance — because it may reduce or eliminate your subsidy, or you may need to switch plans.

Yes — starting a new job must be reported if it changes your household income or provides access to employer-sponsored insurance, since both affect your subsidy eligibility and coverage options.

If you lose health insurance from a job, you have 60 days to sign up for a Marketplace plan — and with lower income, you may now qualify for subsidies or even Medicaid.

Yes — losing job-based health coverage is one of the most common qualifying life events and triggers a 60-day Special Enrollment Period (SEP), during which you can enroll in or change a Marketplace plan.

Getting married or divorced changes who is in your household, which can change what coverage you qualify for. Both events let you update or switch plans within 60 days.

Yes — both marriage and divorce must be reported because they change household size, income, and coverage eligibility, and both can trigger a 60-day Special Enrollment Period.

Yes, you can appeal if the Marketplace denies you coverage, subsidies, or other help. You have 90 days from the notice date to file, and you can do it online, by mail, or by fax.

Yes — you can appeal most Marketplace eligibility decisions, including denials of enrollment, subsidy amounts, cost-sharing reductions, and Special Enrollment Periods. You generally have 90 days from the date on your eligibility notice to file.

If you think the Marketplace got your subsidy wrong — either too low or denied entirely — you can appeal with proof of your actual income. You have 90 days from the notice to do it.

Yes — you can appeal a Marketplace decision about your subsidy (premium tax credit or cost-sharing reduction) amount within 90 days of the eligibility notice, providing documentation to support your income or household claim.

Yes — if the Marketplace denies your request to sign up outside the regular enrollment period, you can appeal. Gather any proof of your life event and submit it within 90 days.

Yes — a denial of a Special Enrollment Period can be appealed within 90 days of the denial notice, and you should include documentation proving the qualifying life event occurred within the required timeframe.

You file the appeal with documents showing why you think the decision was wrong, the Marketplace reviews everything, and sends you a written answer. You can usually keep your coverage going while you wait.

Marketplace eligibility appeals are reviewed by the Marketplace Appeals Center: you submit your appeal with supporting documents, the center reviews the evidence against your eligibility notice, and issues a written decision — typically within 90 days.

For Marketplace eligibility decisions, you have 90 days from the notice date to appeal. For insurance claim denials, you typically have 180 days to ask the insurer to reconsider.

Yes — the standard deadline to file a Marketplace eligibility appeal is 90 days from the date printed on the Marketplace Eligibility Notice. For plan-level (insurance company) internal appeals, you generally have 180 days from the denial notice.

The basic ACA protections are the same everywhere, but big things like when enrollment ends, whether Medicaid is available, and extra financial help vary a lot from state to state.

No — while the core ACA federal requirements apply in every state, there are significant state-level differences in Marketplace type, open enrollment deadlines, Medicaid expansion status, additional subsidies, and state-specific rules.

HealthCare.gov is a federally run website most states use to sign up for health insurance. But 21 states have their own websites and their own rules — if you live in one of those, you use their site instead.

HealthCare.gov is the federally run Marketplace used by most states; state Marketplaces (SBEs) are operated by individual states with their own websites, enrollment systems, and sometimes additional subsidies or broader rules.

The health plans available to you depend on where you live, right down to your county. People in different counties of the same state may have very different plan options and prices.

Yes — plan availability varies significantly by county and state, since health insurers choose which counties to serve and plans are sold within specific geographic service areas defined at the county level.

Medicaid rules are different in every state, especially whether adults without children can get it. In 10 states, there's a 'coverage gap' where some low-income adults can't get Medicaid or Marketplace help.

Yes — Medicaid eligibility rules, income thresholds, covered services, and enrollment processes vary significantly by state, with the most important divide being whether the state has expanded Medicaid under the ACA.

In most states your subsidy is determined by federal rules, but California, Colorado, Connecticut, Maryland, Massachusetts, and New Mexico are also providing extra state help in 2026 — so your subsidy amount depends on where you live.

Yes — while federal subsidy formulas apply nationally, some states have added their own state-funded subsidies on top of federal APTC, meaning subsidy amounts and eligibility thresholds can differ significantly by state for 2026.

Agents should never make promises about what a plan covers, what it costs, or what subsidies will be before actually looking it up with current data. If you're not sure, say so and look it up.

Agents must never promise specific premium amounts, guaranteed coverage of specific doctors or drugs, guaranteed subsidy amounts, or specific benefits from a plan without verifying current, official plan data — all such representations must be based on documented, current facts.

Agents can't promise a doctor is covered — networks change. Always have the client call the doctor's office or check the plan's official directory before enrolling, especially if a specific doctor is the reason for choosing that plan.

No — an agent cannot guarantee that any specific doctor is in-network. Agents must direct consumers to verify provider status directly through the plan's official provider directory or by calling the provider's office.

Agents can't promise a specific drug will be covered. Always check the plan's drug list (formulary) before enrolling, especially if the medication is expensive or there are no good alternatives.

No — an agent cannot guarantee that a specific medication will be covered or at what cost-sharing tier. Formularies change annually (and sometimes mid-year), and coverage depends on the plan's current formulary, tier, and any applicable prior authorization or step therapy requirements.

When talking about subsidies, use the actual numbers from the Marketplace — not guesses. Always explain that the amount could change based on actual income at tax time, and never inflate the estimate to make a plan look cheaper.

Agents should discuss subsidies in terms of how the formula works, run accurate estimates using current Marketplace tools, make clear that estimates are based on provided income and may change at tax reconciliation, and never guarantee a specific dollar amount.

Agents cannot pick a plan and sign someone up without that person's clear agreement. The client must review the application and choose the plan — the agent is there to help, not to decide.

No — agents cannot choose a plan for a client without their knowledge and consent. CMS requires that agents obtain consumer consent, review the application with the consumer for accuracy, and have the consumer affirm their plan selection before submitting.

Start every call by getting permission, finding out where the client lives, who's in their household, their income, and whether they have any other insurance — that information shapes everything that comes next.

A strong first-call ACA intake workflow covers: confirm consent, gather basic household and income data, determine state and enrollment window, screen for SEP or OEP, check for employer coverage or Medicaid eligibility, then compare plans before discussing options.

Before showing a client any plans, you need their zip code, everyone in the household, their income, their current insurance, and what health care they use — you can't find the right plan without all of this.

Before discussing plans, an agent should gather: state of residence and zip code, all household members and their ages, projected 2026 annual income (MAGI), current insurance status and end date, any qualifying life events, employer coverage offers, and any specific health care needs (doctors, medications).

Ask the client if anything major happened in the last 60 days — lost insurance, got married, had a baby, moved. Any of those events might give them a special window to sign up for coverage even outside Open Enrollment.

To screen for SEP eligibility, ask about any recent life changes: job loss, marriage, birth/adoption, move, loss of Medicaid/CHIP, or other coverage changes. If a qualifying event occurred within the past 60 days (or is expected within 60 days), the consumer likely has an SEP.

Ask if the client's employer offers health insurance and what the monthly cost is. If the employer's plan is affordable (under about $132/month for self-only in 2026), the client probably can't get a subsidy on the Marketplace.

Ask whether any household member currently has access to employer-sponsored coverage, what the employee-only monthly premium is, and whether the plan provides minimum value. These facts determine subsidy eligibility even if the consumer prefers a Marketplace plan.

Before showing someone Marketplace plans, check whether they or their household might qualify for free or low-cost Medicaid or CHIP — especially if their income is below about $22,000 for one person or $45,000 for a family of four.

Screen for Medicaid and CHIP by asking about household income relative to FPL and household members' ages. In the 40 Medicaid-expansion states, adults at or below 138% FPL generally qualify for Medicaid; children and pregnant individuals may qualify at higher income levels through CHIP.