Who Shops on the Marketplace?
The health insurance marketplace provides a way for people to purchase health insurance to meet their needs. To be eligible to purchase health insurance from the healthcare marketplace, you need to be an American citizen or national. You may be able to purchase insurance policies for yourself and your family if you are looking for insurance in the following instances:
- You are self-employed.
- Your employer does not provide you with health insurance.
- You need health insurance for yourself or your family.
- You are unemployed and do not have insurance through other forms.
If you qualify for Medicare, you cannot purchase health insurance through the healthcare marketplace. You will need to use the Medicare.gov website to make this purchase. Also, others may be restricted from purchasing this insurance, including those who are incarcerated.
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Essential Health Benefits
You will find access to health insurance policies that offer these 10 essential health benefits:
- Ambulatory patient services: This includes outpatient care received
- Emergency services: Medical care stemming from emergency rooms or emergency response teams
- Hospitalization: Including in-hospital care, overnight care, in-hospital rehabilitation, surgeries
- Pregnancy: This includes maternity care (or care for the mother), pregnancy care during the pregnancy for both, and newborn care
- Mental health care: Mental health and substance use disorder treatment, including behavioral health treatment including outpatient therapy
- Prescription medications: Medications prescribed by a licensed doctor
- Rehabilitative services: Recovery and rehab after injuries or for chronic conditions
- Lab services: Blood work, x-rays, and other diagnostics
- Preventative care: Routine preventive care, wellness services, and chronic disease management
- Pediatric care: Care for children, including oral and vision care. (Note: While pediatric dental and vision must be offered, adult dental and vision coverage is not an EHB.
How Does the Marketplace Work?
It is easy to access and use the marketplace. Follow these steps:
- Use the tools on the website to check eligibility for coverage, including verification of being a U.S. citizen living in the country.
- Provide information about your needs. Explore plan options displayed for your local area.
- Compare policies, including policy coverages, types of limitations, out-of-pocket costs, covered care providers, and more.
- Choose the policy right for you. You will see coverage, costs, and limitations associated with ease.
- Enroll in the plan. Before enrolling, you will need to share sensitive information about your identity and verify your eligibility.
Carefully consider your previous coverage and choose marketplace health coverage that matches your future needs. You can find affordable healthcare insurance that fits your care needs.
Compare Health Plans
Health insurance through the healthcare marketplace is a very diverse resource. It provides you with a list of all health insurance policies on the marketplace that fit your eligibility criteria, such as your age and needs. You will provide some basic information about the tool, and it will provide you with a list of available policies from which to select. You will then need to consider the options. Consider:
- Plan coverage: Look at what the plan covers and what it does not. Specifically, consider whether your medical services are available, where you can receive care, and if there are any restrictions on access to medications or providers you already have.
- Consider the network: Look at all providers within the network to ensure they are close to you.
- Consider the costs: You will see the premium cost to pay for the insurance listed. You will also see information about out-of-pocket costs, co-pays, and any services not covered. Be sure to consider how much coverage you have, as well as your limits and maximum coverage allowances.
The tools on the HealthCare.gov website are comprehensive. You can click through them to get more information or clarification. Take the time to look at several policies and plans, examining how well they may fit your needs.
Understand Out-of-Pocket Costs
As you consider each of the options for the coverage year, always consider costs. Specifically, consider out-of-pocket costs. This should include any costs you have to pay before the insurance policy will cover your claims. Policies differ in the insurance marketplace significantly, but some common costs include:
- Deductible: The amount you must pay first before your health insurance policy pays out. It resets each year.
- Co-payments: You may have to make these payments when you receive service from providers. Consider how much they are and when they apply.
- Co-insurance: This is the percentage of the cost of covered services you pay after you’ve met your deductible. It is not dependent on having another provider.
Also, note the Out-of-Pocket Maximum, which is the most you pay in deductibles, copayments, and co-insurance for covered services in a year. For 2026, the federal maximum for an individual is $10,600 and $21,200 for a family.
How Much Will Your Plan Cost?
Marketplace medical insurance cost is dependent on various factors. Specifically, it is dependent on your specific needs. This includes the type of coverage you obtain and the level of coverage you elect. Health insurance marketplaces offer details related to your specific costs based on the information you provide about your desired coverage.
For 2026, the average unsubsidized (gross) premium of the Affordable Care Act Marketplace is increasing by a median of 18% nationally, and often more in states using HealthCare.gov. This reflects inflation and rising healthcare costs.
Marketplace enrollees may benefit from subsidies. However, a major change is coming for 2026: The enhanced federal subsidies are scheduled to expire, meaning millions of Americans will see their net monthly premiums more than double on average, and high-income households will lose subsidies entirely (the ‘subsidy cliff’ returns). Reviewing your eligibility for 2026 is critical to determine your actual cost.
However, if you have not reviewed your policy yet, doing so is critical. You must ensure you are still eligible for any subsidy received.
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