11/20/2025
Health Insurance 101 -- Start here-- updating to information**
Topics:
What is the ACA?
What is Open Enrollment?
Why Do We Have Open Enrollment?
Why Do You Need Health Insurance?
What is the marketplace?
State specific websites for their marketplace
Who is in my household?
What is the APTC And who is eligible?
What is FPL?
How the FPL and the APTC work together
What happens if I don't enroll in health insurance?
What about the tax penalty?
Let's talk about plan structures
What is a Deductible?
Coinsurance?
Copayment
Out of Pocket Maximum
Short Term Health Plans
Primary and secondary coverage
No Surprise Act
What is the ACA?
The Affordable Care Act is a comprehensive health care reform law enacted in March 2010 sometimes known as ACA, PPACA, or “Obamacare”.
The law has 3 primary goals:
Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level.
Expand the Medicaid program to cover all adults with income below 138% of the federal poverty level. (Not all states have expanded their Medicaid programs.)
Support innovative medical care delivery methods designed to lower the costs of health care generally.
With regard to your employer, if your employer has over 50 employees, they are required to provide you a compliant insurance that meets Minimum Essential Coverage and Minimum Value standards. Your employer also must subsidize at least 50% of the premium to enroll the employees.
What is Open Enrollment?
https://www.healthcare.gov/quick-guide/dates-and-deadlines
https://www.healthcare.gov/glossary/open-enrollment-period/
The yearly period when people can enroll in a health insurance plan. Open Enrollment for 2026 runs from November 1, 2025 through Dec 15, 2025.
Insurance plans elected during Open Enrollment before December 15th, will start January 1, 2025 unless you select a private, non ACA option. ACA Plans cannot be selected after December 15 unless you have SEP, below or choose a private plan.
Outside the Open Enrollment Period, you generally can enroll in a health insurance plan only if you qualify for a Special Enrollment Period. You’re eligible if you have certain life events, like getting married, having a baby, or losing other health coverage.
Why do we have Open Enrollment (OE)?
OE is designed for anyone eligible to purchase on the marketplace to make their elections for 2026. With the introduction of the ACA legislation, you cannot buy ACA insurance whenever you want – this prevents people from enrolling only when they know they need the health insurance, which drives up prices for everyone.
Why do you need health insurance?
Medical costs are the leading cause for bankruptcy in the US, and everyone is always healthy until they are not. By enrolling in an ACA compliant healthcare plan, you receive the benefits of a provider network, contracted negotiated rates on services, an out of pocket max which caps your personal spending each year, and other state/federal protections on your healthcare experience.
What is the marketplace and who can use it?
Any US citizen or qualifying immigration status (https://www.healthcare.gov/immigrants/immigration-status/) that is not incarcerated may purchase health insurance off of the marketplace. Please only use healthcare.gov for finding marketplace insurance!
Some states have their own marketplace websites:
California: Covered California
Colorado: Connect for Health Colorado
Connecticut: Access Health CT
District of Columbia: DC Health Link
Idaho: Your Health Idaho
Kentucky: Kynect
Maine: CoverMe
Maryland: Maryland Health Connection
Massachusetts: Health Connector
Minnesota: MNsure
Nevada: Nevada Health Link
New Jersey: Get Covered NJ
New Mexico: beWellnm
New York: NY State of Health
Pennsylvania: Pennie
Rhode Island: HealthSource RI
Vermont: Vermont Health Connect
Virgina: Marketplace.virginia.gov
Washington: WA Healthplanfinder
Who is in my Household?
Household = you, spouse, tax dependents. It is not necessarily who you physically live with.
What is the APTC and who is eligible?
The APTC stands for Advanced Premium Tax Credit and is a subsidy provided to people with incomes between 138 – 400% of the Federal Poverty Level. If your state has not expanded Medicaid, the income becomes 100 – 400% of the Federal Poverty Level. You are eligible for the APTC if your income falls in this range and you have no employer insurance available. If you are Medicaid eligible, you should apply there as you will not qualify for the APTC; however, you are welcome to purchase a full price marketplace plan instead if you prefer.
What is the Federal Poverty Level (FPL)?
The Federal Poverty Level/Line is a measure of income issued every year by the Department of Health and Human Services (HHS). Federal poverty levels are used to determine your eligibility for certain programs and benefits, including savings on Marketplace health insurance, and Medicaid and CHIP coverage.
The 2024 federal poverty level (FPL) income numbers below are used to calculate eligibility for Medicaid and the Children's Health Insurance Program (CHIP). 2023 numbers are slightly lower, and are used to calculate savings on Marketplace insurance plans for 2024.
Family Size 2023 Income numbers 2024 Income numbers
Individuals $14,580 $15,060
Family of 2 $19,720 $20,440
Family of 3 $24,860 $25,820
Family of 4 $30,000 $31,200
Family of 5 $35,140 $36,580
Family of 6 $40,280 $41,960
Family of 7 $45,420 $47, 340
Family of 8 $50, 560 $52,720
Family of 9 or more Add $5,140 for each additional person Add $5,380 for each additional person
*note: Hawaii and Alaska both have higher poverty levels.
How the FPL and APTC work together:
Income above 400% FPL: If your income is above 400% FPL, you may now qualify for premium tax credits that lower your monthly premium for a Marketplace health insurance plan.
Income between 100% and 400% FPL: If your income is in this range, in all states you qualify for premium tax credits that lower your monthly premium for a Marketplace health insurance plan.
Income at or below 150% FPL: If your income falls at or below 150% FPL in your state and you’re not eligible for Medicaid or CHIP, you may qualify to enroll in or change Marketplace coverage through a Special Enrollment Period.
Income below 138% FPL: If your income is below 138% FPL and your state has expanded Medicaid coverage, you qualify for Medicaid based only on your income.
Income below 100% FPL: If your income falls below 100% FPL, you probably won’t qualify for savings on a Marketplace health insurance plan or for income-based Medicaid.
What happens if I don't enroll in a plan during open enrollment?
If you don’t enroll in an ACA-compliant health insurance plan by the end of open enrollment, your buying options will likely be very limited for the coming year. Open enrollment won’t come around again until November 2026, with coverage effective the first of the following year.
But depending on the circumstances, you might still be able to get coverage after open enrollment ends:
If relatively health, You may get a private, non-ACA plan. These are usually half cost of ACA plans witn no copays, zero deductibIe from major companies like Humana, UnitedHealthcare, Aetna.
Medicaid and CHIP enrollment are available year-round for those who qualify.
Native Americans can enroll year-round
Special enrollment period if you have a qualifying event
Will I have to pay a fee if I don't have insurance?
If you didn’t have coverage during 2024, the fee no longer applies. This means you don’t need an exemption in order to avoid the penalty. However, some states charge a fee if you don't have health coverage. If you live in a state that requires you to have health coverage and you don’t have coverage (or an exemption), you’ll be charged a fee when you file your state taxes. These states are: California, District of Columbia, Massachusetts, New Jersey, and Rhode Island.
Let’s talk about Plan Structures
Metal tiers are a quick way to categorize plans based on what that split is.
Some people get confused because they think metal tiers describe the quality of the plan or the quality of the service they’ll receive, which isn’t true.
Here’s how health insurance plans roughly split the costs, organized by metal tier:
Bronze – 40% consumer / 60% insurer
Silver – 30% consumer / 70% insurer
Gold – 20% consumer / 80% insurer
Platinum – 10% consumer / 90% insurer
The minimum you’ll spend per year is the annual cost of your premiums.
The maximum you’ll spend per year is the sum of the annual premium plus the out of pocket maximum.
If you don’t intend to max out the plan with expected medical costs, you should calculate your estimated costs. This could be the sum of the annual premiums + deductible. If your plan has copays, it would be the sum of the annual premiums + copays on services you know you need.
What is a deductible?
The amount you pay for covered health care services before your insurance plan starts to pay.
With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.
Coinsurance
The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.
If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
If you haven't met your deductible: You pay the full allowed amount, $100.
Copayment
A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20.
If you've paid your deductible: You pay $20, usually at the time of the visit.
If you haven't met your deductible: You pay $100, the full allowable amount for the visit.
Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.
Out of Pocket Maximum
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
The out-of-pocket limit doesn't include:
Your monthly premiums
Anything you spend for services your plan doesn't cover
Out-of-network care and services
Costs above the allowed amount for a service that a provider may charge
The out-of-pocket limit for Marketplace plans varies, but can’t go over a set amount each year.
Short Term Health Plans
Under general federal rules, short-term health insurance plans can have initial terms of up to 364 days and a total duration of up to 36 months, including renewals. But the majority of the states placed more restrictive limits on the availability of short-term plans, and those state limits supersede the new federal rules. Every state has its own rules, please check with your states department of insurance to see if your state has limitations to short term plans. These are also generally NOT ACA-compliant plans. As a whole, this subreddit does not encourage short term plans, but if the option is short term plan or bankruptcy, we would encourage some coverage.
I have two or more insurances. How do I know which one is primary and which is secondary?
This is called a Cordination of Benefits. Each insurance you are covered by needs to know who is going to pay the most for your health care, and that will be your primary insurance. All insurances want to be the last payor, so it's important you know who is in charge of paying the most.
Your primary will be the coverage where you are the policy holder (aka subscriber). In the case of two commercial insurances where you are the policy holder on both, this can be tricky. Generally in that case, the insurance you've had longer would be primary and the other secondary. Please see below if there is a non commercial insurance involved.
Next, secondary coverage will be anything you are a dependent on. If you are under 26, this might be your parents insurance. It could be your spouses policy.
If you are over 65 and you are working, or have a spouse who is working and you are covered under their policy, that insurance will be primary over Medicare benefits.
Now, if there are two policies and one is Tricare or Medicaid, those will be the payors of last resort, meaning you will always have a commercial policy be primary over Tricare and Mediciad if there is a commercial insurance involved. In the case of having both Tricare and Medicaid, Medicaid will be the last payor. For example, say a patient has Tricare, Aetna, and Medicaid. The order of benefits would be Aetna (regardless if they are the policy holder or not), Tricare, and then Mediciad.
Finally, Tricare for Life can only be secondary to Medicare or a Medicare Advantage plan.
It is important that your insurances know who is primary in the chain of your benefits. Whenever you gain a new insurance, call all insurances involved and ask to update your Cordination of Benefits. Some insurances will deny claims until this is done, meaning you will be responsible for the full bill until you call your insurance. A billing office or provider cannot update your coordination of benefits for you as that would be a violation of HIPAA.
What is the No Surprises Act and why is it important?
Starting for dates of service (aka the date of appointments, encounters, or ER trips) January 1, 2022 patients have billing protection from the a federal law called the No Surprises Act (NSA). The NSA states when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers, the patient is protected from outrageous bills. The NSA aims to protect consumers, excessive out-of-pocket costs are restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether or not a provider or facility is in-network.
For example, Jane is hit by a car and needs to go to the hospital. She hit her head during the accident and is in and out of consciousness. EMS take a ground ambulance from the accident to the closest emergency room. She receives emergency surgery to fix an internal bleed and also a fractured leg. Jane stays at the hospital for 5 days total. Jane has insurance from her employer and walks out a little worse for wear, but now is worried about all the bills she is going to receive. She has a $500 deductible and $2000 out of pocket max.
In Jane's case, her insurance is suppose to cover nearly all of her care, even if she was taken to an out of network hospital and admitted to the ER. She did not have any choice in who she received care from as it was an emergency situation. If she receives a bill for say the anesthesiologist who was out of network, she would need to call her insurance and see if they have a claim on file and ask it to be reprocessed under the NSA. The most Jane could owe the hospital and it's affiliates is $2000, her out of pocket max.
Now, what isn't covered under the NSA? Unfortunately, there are some issues that Jane will need to handle herself. For example, the ground ambulance ride she took may not be covered by her insurance, and the NSA does not cover ground ambulances. Air ambulances are covered however, Jane was not going to be taken by a helicopter to a hospital for that situation.
If you haven’t applied for insurance on HealthCare.gov before, here's what you need to know about the Health Insurance Marketplace®. To get ready for Open Enrollment, sign up for emails to get deadline reminders and other important information.
