A step-by-step guide to selecting and enrolling in health insurance, covering marketplace options, plan types, cost comparison, and enrollment deadlines.
Children can stay on a parent's plan until age 26 regardless of student status, income, or marital status. This applies to all marketplace and employer plans. Adding a child typically costs $100-$300 per month.
Review your medical usage from the past 12 months
Count doctor visits, prescriptions filled, lab tests, and any procedures. The average American has 3-4 doctor visits per year. If you had fewer than 2 visits and take no regular medications, a high-deductible plan may save you $1,000-$2,000 annually.
Identify any ongoing treatments or planned procedures
If you are managing a chronic condition or planning a surgery, a plan with a lower deductible and lower coinsurance will likely cost less overall. A single hospital stay averages $13,000-$16,000 before insurance.
Check if your current doctors accept the plans you are considering
Narrow-network plans cost 15-20% less in premiums but limit your choice of providers. Use each insurer's online provider directory to verify that your primary care doctor and any specialists are in-network before enrolling.
Understand Plan Types and Metal Tiers
Learn the difference between HMO, PPO, EPO, and POS plans
HMOs require referrals and have the smallest networks but lowest premiums. PPOs offer out-of-network coverage but cost 20-30% more. EPOs have no out-of-network coverage but do not require referrals. Choose based on how much flexibility you need.
Understand Bronze, Silver, Gold, and Platinum tiers
Bronze plans cover 60% of costs (you pay 40%). Silver covers 70%, Gold 80%, and Platinum 90%. Bronze works best if you are healthy and want low premiums. Silver is the only tier eligible for cost-sharing reductions if your income is 100-250% of the federal poverty level.
Consider a High-Deductible Health Plan paired with an HSA
HDHP deductibles must be at least $1,650 for individuals or $3,300 for families in 2026. HSAs allow pre-tax contributions up to $4,300 (individual) or $8,550 (family). HSA funds roll over year to year and earn tax-free investment growth.
Check whether a catastrophic plan is available to you
Catastrophic plans are available to people under 30 or those with a hardship exemption. Monthly premiums are the lowest available, but deductibles exceed $9,000. These plans cover 3 primary care visits per year before the deductible.
Calculate and Compare Costs
Compare total annual costs, not just monthly premiums
Total cost = (monthly premium x 12) + deductible + estimated copays and coinsurance. A plan with a $200/month premium and $3,000 deductible may cost more than one with $350/month and a $500 deductible if you use moderate care.
Check if you qualify for premium tax credits or subsidies
Households earning 100-400% of the federal poverty level (about $15,000-$62,000 for an individual in 2026) qualify for premium tax credits. Enhanced subsidies cap premiums at 8.5% of income. About 87% of marketplace enrollees receive subsidies.
Verify your prescription drug costs under each plan
Check each plan's formulary for your medications. Tier 1 generics may cost $5-$20, while Tier 4 specialty drugs can cost $200-$500 per fill even with insurance. A single expensive medication can make a higher-premium plan cheaper overall.
Note the out-of-pocket maximum for each plan
The 2026 marketplace out-of-pocket maximum is approximately $9,450 for individuals and $18,900 for families. Once you hit this cap, the plan pays 100%. This is your worst-case annual spending and matters most for serious illness or injury.
Enrollment Process
Create an account on HealthCare.gov or your state marketplace
Fifteen states plus DC run their own marketplaces. Check whether your state has one, as deadlines may differ. Have your Social Security number, immigration documents (if applicable), and employer information ready for the application.
Complete the application with accurate household income
Report your projected annual income for the coverage year, not last year's income. Underestimating income means you may owe back premium tax credits at tax time. Overestimating means you pay higher premiums monthly but get a refund in April.
Submit enrollment before the deadline
Open enrollment typically runs November 1 through January 15. Enrolling by December 15 starts coverage January 1. Missing the deadline means you must wait until next year unless you qualify for a Special Enrollment Period triggered by life events like marriage, birth, or job loss.
Pay your first premium to activate coverage
Your coverage does not start until you pay the first month's premium. Most insurers require payment within 30 days of enrollment. Set up autopay to avoid accidental lapses; missing 2 consecutive payments can result in termination.
Post-Enrollment Setup
Save your plan documents, member ID, and group number
Store digital copies of your insurance card in your phone's photos and a secure cloud folder. Your member ID is required for every doctor visit, pharmacy fill, and insurance claim. Most insurers also offer a mobile app with a digital ID card.
Select a primary care physician within your network
HMO plans require a PCP selection before you can access care. Even with PPOs, having an established PCP ensures continuity. Patients with a regular primary care doctor have 19% lower total healthcare costs than those who rely on urgent care.
Schedule your free annual preventive visit
All ACA plans cover preventive services at 100% with no copay, including annual checkups, immunizations, cancer screenings, and blood pressure checks. About 60% of insured adults skip these free benefits each year.
Set a calendar reminder 2 months before next open enrollment
Plans, premiums, and provider networks change annually. Auto-renewal keeps your plan but does not account for price increases or network changes. Actively comparing plans each year saves an average of $300-$600 in premiums.
Frequently Asked Questions
When is open enrollment for health insurance?
The ACA marketplace open enrollment runs from November 1 to January 15 each year. Employer-sponsored plans typically have a 2-4 week enrollment window in October or November. If you miss open enrollment, you can only enroll during a Special Enrollment Period triggered by a qualifying life event like job loss, marriage, birth of a child, or moving to a new state.
What is the difference between an HMO and a PPO plan?
HMO plans require you to choose a primary care doctor and get referrals to see specialists; they cost 15-20% less in premiums but limit you to in-network providers. PPO plans let you see any doctor without referrals and cover some out-of-network care at a higher cost. If you see specialists often or travel frequently, a PPO offers more flexibility.
How do I know if I qualify for a subsidy on the ACA marketplace?
Premium tax credits are available if your household income is between 100-400% of the federal poverty level (about $15,060-$60,240 for a single person in 2025). Enhanced subsidies through 2025 also cap marketplace premiums at 8.5% of income for higher earners. Enter your income at healthcare.gov to see your exact subsidy amount before choosing a plan.
What does the out-of-pocket maximum mean?
The out-of-pocket maximum is the most you will pay for covered services in a plan year. For 2025, the ACA caps this at $9,200 for individuals and $18,400 for families. Once you hit this amount, your insurance covers 100% of covered services for the rest of the year. This cap includes deductibles, copays, and coinsurance but does not include premiums.
Should I choose a high-deductible plan with an HSA?
An HDHP with an HSA works well if you are generally healthy and can afford to cover the higher deductible ($1,650+ for individuals in 2025). HSA contributions are tax-deductible, grow tax-free, and can be withdrawn tax-free for medical expenses. You can contribute up to $4,300 per year as an individual. The HSA rolls over every year, making it a powerful long-term savings tool.