Health Insurance FAQs

A health insurance premium is the amount you pay to keep coverage in force, usually billed monthly. You pay the premium whether or not you use medical care.

Premiums generally do not count toward your deductible or out-of-pocket maximum. Eligible Marketplace enrollees may qualify for a premium tax credit that lowers the amount they pay each month.

A deductible is the amount you must pay for certain covered services before your plan begins paying its share for those services. A $2,000 deductible does not necessarily mean every medical service is paid entirely by you until you spend $2,000 — some plans provide copays or other benefits before the deductible is met.

ACA-compliant plans also cover specified preventive services without cost sharing when requirements are met, even before the deductible.

A copay is a fixed dollar amount you pay at the time of a specific covered service — for example, $35 for a primary care visit or $15 for a generic prescription. Whether copays apply before or after your deductible depends on your plan’s design.

Copays are predictable costs — you know what you’ll pay before the appointment. See our insurance basics guide for a full explanation of how copays interact with your deductible and coinsurance.

Coinsurance is a percentage of the plan’s allowed cost that you pay for a covered service. It often applies after you meet a deductible, although plan designs vary.

Example: If a covered service has a $1,000 allowed amount and your coinsurance is 20%, your share would generally be $200 once the applicable deductible requirements have been satisfied.

The out-of-pocket maximum is the most you pay in a plan year for covered, in-network benefits that count toward the limit. After you reach it, the plan pays 100% of covered in-network benefits for the rest of that plan year.

Premiums, non-covered services, many out-of-network charges, and amounts above a plan’s allowed amount generally do not count. For 2026 Marketplace plans, the federal limit is no more than $10,600 for an individual or $21,200 for a family. See HealthCare.gov’s out-of-pocket limit guidance.

In-network providers have contracted rates with your health plan. Using them usually results in lower cost sharing. Out-of-network care may cost substantially more, and some plan types provide little or no non-emergency out-of-network coverage.

Before scheduled care, check the insurer’s current provider directory and confirm the specific doctor, facility, and service location when possible. See our health insurance comparison guide for how network rules differ among HMO, PPO, EPO, and POS plans.

Start with the plan’s Summary of Benefits and Coverage (SBC), provider directory, drug formulary, and full plan documents. The SBC summarizes major benefits, exclusions, deductibles, copays, and coinsurance.

ACA-compliant individual and small-group plans generally must cover the 10 essential health benefit categories. Short-term coverage is not required to provide the same protections or benefit package.

A Health Savings Account (HSA) is a tax-advantaged account that eligible individuals can use for qualified medical expenses. To contribute, you generally must be covered by an HSA-eligible high-deductible health plan and meet the other IRS eligibility rules.

For 2026, the HSA contribution limit is $4,400 for self-only coverage and $8,750 for family coverage. IRS rules also define the deductible and out-of-pocket limits an HSA-eligible HDHP must satisfy. See IRS Rev. Proc. 2025-19 and our health insurance basics guide.

Monthly premiums vary widely based on plan type, metal tier, age, location, household details, and eligibility for Marketplace savings. There is no single national monthly price that accurately represents what you will pay.

The most accurate way to find your cost is to enter your ZIP code and income at Healthcare.gov or use our free quote tool. Don’t assume coverage is unaffordable before checking subsidy eligibility.

Compare more than the monthly premium. A useful estimate is annual premiums + the medical and prescription cost sharing you reasonably expect to pay. Consider the deductible, copays, coinsurance, out-of-pocket maximum, provider network, and drug coverage.

For a low-use year, premiums may dominate. In a high-use year, the out-of-pocket limit and network rules can matter much more. Use the plan’s SBC and Marketplace comparison tools, then see our guide to choosing the right health insurance plan.

COBRA can let certain workers and family members temporarily continue the same employer-sponsored group health coverage after a qualifying event such as job loss or reduced hours.

Qualified beneficiaries can generally be charged up to 102% of the total plan cost — the employee and employer shares combined, plus the permitted administrative charge. Compare COBRA’s premium, network, and benefits against Marketplace coverage before deciding.

Depending on income, household, age, state, and other eligibility rules, you may qualify for free or low-cost coverage through Medicaid, CHIP, or Marketplace savings.

In Medicaid-expansion states, many adults under 65 can qualify based largely on income up to about 138% of the federal poverty level, but state rules differ. CHIP eligibility limits also vary. See our low-income health insurance guide for a clearer program-by-program breakdown.

It depends. Self-employed individuals may be eligible for a self-employed health insurance deduction for qualifying premiums, subject to IRS rules and limitations. The IRS now uses Form 7206 in situations where that form is required to calculate the deduction.

For employees, premiums paid through a pre-tax employer arrangement are generally already excluded from taxable income. Other medical-expense deduction rules and limitations may apply to premiums paid with after-tax dollars. Review current IRS guidance or consult a tax professional for your situation.

A Cost-Sharing Reduction (CSR) is extra Marketplace savings that can lower deductibles, copays, coinsurance, and out-of-pocket limits for eligible households. To receive CSR savings, you generally must choose a Silver Marketplace plan.

A key rule: CSRs only apply to Silver-tier plans. If you qualify for a CSR and choose a Bronze or Gold plan instead, you won’t receive the additional cost-sharing help. For qualifying households, a Silver plan with CSR can have cost-sharing comparable to a Gold or even Platinum plan.

The allowed amount is the maximum amount your plan recognizes for a covered service under its contract or payment rules. For in-network care, the provider’s negotiated rate is often lower than the provider’s original billed charge.

Your deductible, copay, or coinsurance is usually calculated from the plan’s allowed amount rather than the provider’s sticker price. This is one reason the amount on a medical bill can differ from the amount shown on an Explanation of Benefits.

Medical prices can vary because insurers negotiate different rates, facilities charge differently, provider networks differ, and the exact service or billing code may not be identical. Your own cost also depends on where you are in your deductible and which cost-sharing rules apply.

For scheduled care, ask the provider for a good-faith estimate when available and use your insurer’s cost-estimator or member tools. Then verify whether the facility and clinicians are in-network. See the federal No Surprises Act resources from CMS for additional billing protections.

The Affordable Care Act (ACA) established consumer protections and standards for individual and small-group health coverage, including protections for people with pre-existing conditions and required essential health benefit categories for applicable plans.

Marketplace plans sold through HealthCare.gov or a state exchange are ACA-compliant plans and may qualify for income-based savings. Read our ACA health insurance guide for metal tiers, networks, subsidies, and enrollment rules.

For 2026, the general federal income range for the Premium Tax Credit is at least 100% and no more than 400% of the federal poverty line for the tax family, with limited exceptions below 100% FPL. Meeting the income range alone does not guarantee eligibility.

Other rules include Marketplace enrollment, tax-filing requirements, and whether you are eligible for affordable employer coverage or certain government programs. See the IRS Premium Tax Credit Q&A and our low-income coverage guide.

Marketplace plans use Bronze, Silver, Gold, and Platinum metal levels to describe how a plan is expected to split covered medical costs across a standard population. The metal level does not measure quality of care.

• Bronze: about 60% plan / 40% enrollee on average
• Silver: about 70% / 30% on average; Cost-Sharing Reductions apply only to eligible Silver plans
• Gold: about 80% / 20% on average
• Platinum: about 90% / 10% on average where offered

Your own spending can differ substantially from these averages. Compare the premium, deductible, network, prescriptions, and out-of-pocket maximum for each actual plan.

No. ACA Marketplace plans cannot deny coverage, charge higher premiums, or impose waiting periods based on any pre-existing medical condition — from asthma and diabetes to cancer and heart disease. This is one of the most significant consumer protections in the Affordable Care Act.

Short-term health insurance is not ACA-compliant and does not provide the ACA’s pre-existing-condition protections. If ongoing medical needs are important to your decision, compare comprehensive ACA coverage carefully before considering a short-term policy.

Medicaid is a joint federal-state program that provides free or low-cost coverage to eligible people. In states that expanded Medicaid under the ACA, many adults can qualify based largely on income, generally up to about 138% of the federal poverty level. Eligibility rules differ by state.

Non-expansion states have more restrictive eligibility rules. Check your state’s Medicaid agency or visit Healthcare.gov to screen for eligibility. See our low-income coverage guide for a full breakdown.

CHIP provides free or low-cost coverage for eligible children and, in some states, pregnant people in families whose income is too high for Medicaid. Income limits and program rules vary by state.

CHIP has no enrollment window — you can apply year-round. Premiums are typically very low or zero. Learn more at Medicaid.gov/CHIP or visit our low-income guide.

For HealthCare.gov, annual Marketplace Open Enrollment runs from November 1 through January 15. The upcoming Open Enrollment for 2027 coverage begins November 1, 2026.

Enroll by December 15 for coverage that can start January 1; enrollment from December 16 through January 15 generally starts February 1. State-based Marketplaces can use different deadlines. See HealthCare.gov dates and deadlines.

If you miss the ACA open enrollment window and don’t have a qualifying life event, your options include:

• Short-term health insurance: May be available outside ACA Open Enrollment depending on your state and current rules; benefits and underwriting can be limited
• Medicaid: If you’re income-eligible, apply any time of year at Medicaid.gov
• COBRA: If you recently left a job, you may have 60 days to elect COBRA continuation
• Wait for next open enrollment: Starting November 1 each year

Before going without coverage, compare Special Enrollment, Medicaid or CHIP eligibility, COBRA if applicable, and any temporary options legally available in your state.

A qualifying life event can open a Special Enrollment Period (SEP) outside Open Enrollment. The enrollment window is often 60 days before or after the event, depending on the event and Marketplace rules. Common qualifying events include:

• Losing job-based health coverage
• Getting married or divorced
• Having a baby or adopting a child
• Moving to a new ZIP code or state
• Turning 26 and aging off a parent’s plan
• Change in immigration or citizenship status

Full list at Healthcare.gov SEP List. Timing rules vary by qualifying event, so check the Marketplace requirements as soon as the change occurs.

You can get enrollment help from several sources:

• Marketplace Navigators and certified assisters: trained to help consumers use the Marketplace.
• Licensed insurance agents or brokers: may help compare plans; ask how they are compensated and which plans they represent.
• HealthCare.gov: provides online and phone assistance for Marketplace applications and enrollment.

Use HealthCare.gov’s Find Local Help tool for official assistance options.

Self-employed people can shop for individual coverage through the ACA Marketplace, buy qualifying individual coverage outside the Marketplace, join a spouse’s employer plan when eligible, or consider COBRA after leaving prior job-based coverage. Medicaid may also be available based on household circumstances.

Marketplace savings use projected household income under ACA tax rules, so self-employed applicants should estimate income carefully and update changes during the year. See our plan-selection guide and health insurance quote page.

HMO, PPO, EPO, and POS describe provider-network and referral structures. Exact rules vary by insurer and plan:

• HMO: usually focuses on in-network care and may use a primary care physician and referrals.
• PPO: generally offers more provider flexibility and may include out-of-network benefits at higher member cost.
• EPO: generally covers non-emergency care only within its network.
• POS: combines features of HMO and PPO designs and may require referrals while offering some out-of-network benefits.

Compare the actual provider directory, referral rules, and out-of-network benefits for each plan. See our health insurance comparison guide.

An HDHP is a high-deductible health plan defined under federal tax rules. It is a cost-sharing design, not a provider-network type, so an HDHP can also use an HMO, PPO, EPO, or other network structure.

For 2026, an HSA-eligible HDHP must have a deductible of at least $1,700 self-only or $3,400 family, and out-of-pocket expenses cannot exceed $8,500 self-only or $17,000 family, subject to IRS rules. An individual must also satisfy the separate HSA eligibility requirements to contribute. See IRS Rev. Proc. 2025-19.

Short-term health insurance provides temporary medical coverage under rules that vary by state, insurer, and current federal treatment. These plans are not ACA-compliant, may use medical underwriting, may exclude or limit pre-existing conditions, do not have to cover all essential health benefits, and do not qualify for ACA premium tax credits.

It may be one option for certain temporary coverage gaps where the product is available, but compare ACA Special Enrollment and COBRA first when those options apply. See our short-term insurance guide for current limitations and comparison points.

Family coverage can include multiple eligible household members under one policy, but deductibles and out-of-pocket limits are not structured identically across all plans. Some plans use embedded individual limits inside a family limit; others use different designs.

Dependent children can generally remain on a parent’s health plan until age 26. When comparing family coverage, check each person’s doctors, prescriptions, expected care, and the family deductible/out-of-pocket rules. Use our guide to choosing the right health insurance plan.

Catastrophic Marketplace plans are designed mainly to protect against very high medical costs. They cover the same essential health benefits as other Marketplace plans and include at least three primary care visits per year before the deductible is met.

You may qualify for a Catastrophic plan if one is available in your area and you are under 30, or if you qualify for a hardship or affordability exemption. If you qualify for Marketplace savings, compare Bronze and Silver plans as well because they may offer better overall value.

Check the plan’s drug formulary, which is the list of medications the plan covers. Confirm the exact drug name, dosage, formulation, and pharmacy network before enrolling because formularies can differ even among plans from the same insurer.

Also check whether the drug is subject to a deductible, copay, coinsurance, quantity limit, prior authorization, or step-therapy requirement. The plan’s formulary and Summary of Benefits and Coverage are the best starting points.

Drug tiers group covered medications into cost levels. A lower tier often has lower cost sharing, while specialty drugs may be placed in higher tiers. Prior authorization means the insurer requires approval before covering a medication. Step therapy may require trying another covered drug first.

If a needed medication is not covered or a restriction creates a problem, ask the plan about its formulary exception and appeal process before choosing coverage.

Quote tools commonly ask for your ZIP code, ages of the people who need coverage, household size, estimated household income when Marketplace savings are being evaluated, and the type of coverage you are looking for.

You generally do not need to provide a Social Security number just to preview Marketplace plans and prices. Review any privacy notice and consent language before submitting personal information. See our health insurance quotes page.

Yes. You can research prices and plan options throughout the year. However, being able to view a quote does not necessarily mean you can enroll in an ACA Marketplace plan immediately.

Outside Open Enrollment, Marketplace enrollment generally requires a Special Enrollment Period. Medicaid and CHIP accept applications year-round, and other coverage types follow their own availability rules.

A quote request is not the same as completing enrollment. Enrollment requires additional plan selection, eligibility, application, and payment steps as applicable.

If a quote form includes consent to be contacted, review that language carefully before submitting. Contact practices depend on the form and the authorization you give. If you prefer to browse ACA Marketplace plans independently, you can use HealthCare.gov directly.

When you see an in-network provider, the provider typically files the claim on your behalf — you just show your insurance card. For out-of-network care or reimbursement situations, you may need to file manually:

• Obtain an itemized receipt or Explanation of Benefits from the provider
• Complete your insurer’s claim form (available on their website)
• Submit by mail, online, or through your insurer’s app
• Track the claim status and follow the insurer’s stated processing and appeal timelines

If a claim is denied, you have the right to appeal. Request a written denial and consult your insurer’s appeals process — or contact your state insurance commissioner if needed.

An Explanation of Benefits (EOB) is a statement from your insurer showing how a claim was processed — including the provider’s billed charge, the plan’s allowed amount, what the plan paid, and the amount that may be your responsibility.

An EOB is not a bill. Compare it with any bill from the provider. If the amounts or services do not make sense, contact the insurer and provider before paying a disputed amount.

A denied claim may be appealable. Start by reading the denial notice and your plan documents to understand the reason and deadline.

• Request the denial reason and relevant plan provision in writing.
• Submit an internal appeal with supporting records within the stated deadline.
• If eligible, request an external review after the internal process.
• Contact your state insurance department or an appropriate consumer-assistance resource if you need help.

For Marketplace and other applicable plans, see HealthCare.gov’s appeals guidance.