Employer-Sponsored and Individual Insurance

The Patient Protection & Affordable Care Act (ACA) created a new way to find and buy private health insurance plans for individuals and families: State Health Insurance Marketplaces

State Health Insurance Marketplaces are also called “exchanges”
Marketplaces for most states are run by the federal government:
- https://www.healthcare.gov/
- or contact 800-318-2596.
Some states run their own Marketplaces and may have a different name. Click here to find your state’s Marketplace: https://www.healthcare.gov/marketplace-in-your-state/

Eligibility

To be eligible to buy a health plan through the Marketplace, you:

Must live in the United States
Must be a U.S. citizen, or be lawfully present^* in the U.S.
Can’t be incarcerated

If you have Medicare, you may not be eligible to use the Marketplace to buy a health or dental plan

*Note: while anyone who is lawfully present can buy a Marketplace plan, only individuals who are Legal Permanent Residents, certain Cuban and Haitian entrants, and individuals residing under the Compacts of Free Association, are eligible to receive federal financial assistance to buy a Marketplace plan.

Marketplace Plans Benefits

There are benefits to buying a plan through the Marketplace:

Out-of-Pocket Maximum

For 2026, Marketplace plans have an out-of-pocket maximum of no more than $10,600 for an individual and $21,200 for a family.

Out-of-pocket maximums for all Marketplace plans include everything you spend for deductibles, co-payments, and co-insurance for in-network health care providers and prescription drugs.

Plan Levels

Plans sold through the Marketplace are grouped by their level of cost-sharing. The levels are Bronze, Silver, Gold, and Platinum. We will take a closer look at these levels in the next section.

Financial Help

Based on your projected income for the next year, you may qualify for financial help. There are two types of financial help:

“Premium tax credits”: Lower monthly premium based on the plan you chose.
“Cost-sharing subsidies”: Lower co-payment amounts, deductibles, and co-insurance amounts.
- We will take a closer look at Marketplace financial help in the next section

Plan Levels

Plans sold through the Marketplace are grouped by their cost-sharing, broken into levels: bronze, silver, gold, and platinum

Plan Level
(Cost-Share)

Bronze
(Insurance Pays 60%
You Pay 40%)

Silver
(Insurance Pays 70%

You Pay 30%)

Gold
(Insurance Pays 80%
You Pay 20%)

Platinum
(Insurance Pays 90%
You Pay 10%)

Monthly Premium

$$$

$$$$

Deductibles/
Out-of-Pocket Costs

$$$$

$$$

According to HealthCare.gov, this may be a good plan for people who…

Want a low-cost way to protect themselves from worst-case medical scenarios, with a low monthly premium, but higher costs for routine care

Qualify for extra cost reductions, or those who are willing to pay a slightly higher monthly premium than a bronze plan to have more routine care covered

Are willing to pay more each month to have more costs covered for medical treatment, particularly helpful for those who use a lot of care

Use a lot of care and are willing to pay a high monthly premium so that nearly all other costs will be covered

Bronze
(Insurance Pays 60%
You Pay 40%)

Monthly Premium
$

Deductibles/
Out-of-Pocket Costs
$$$$

According to HealthCare.gov, this may be a good plan for people who…
Want a low-cost way to protect themselves from worst-case medical scenarios, with a low monthly premium, but higher costs for routine care

Silver
(Insurance Pays 70%
You Pay 30%)

Monthly Premium
$$

Deductibles/
Out-of-Pocket Costs
$$$

According to HealthCare.gov, this may be a good plan for people who…
Qualify for extra cost reductions, or those who are willing to pay a slightly higher monthly premium than a bronze plan to have more routine care covered

Gold
(Insurance Pays 80%
You Pay 20%)

Monthly Premium
$$$

Deductibles/
Out-of-Pocket Costs
$$

According to HealthCare.gov, this may be a good plan for people who…
Are willing to pay more each month to have more costs covered for medical treatment, particularly helpful for those who use a lot of care

Platinum
(Insurance Pays 90%
You Pay 10%)

Monthly Premium
$$$$

Deductibles/
Out-of-Pocket Costs
$

According to HealthCare.gov, this may be a good plan for people who…
Use a lot of care and are willing to pay a high monthly premium so that nearly all other costs will be covered

^*As a result of the Public Law 119–21, which was signed into law in 2025, more Marketplace plans, including all Bronze and Catastrophic health plans, now can be paired with Health Savings Accounts.

Catastrophic Plans

There is an additional option for certain people, called catastrophic plans, which have low monthly premiums and very high deductibles. If you qualify for the premium tax credit or cost-sharing reductions, a Bronze or Silver plan may be a better value. Be sure to compare your options.

Plan Level (Cost-Share)	Monthly Premium	Deductibles/ Out-of-Pocket Costs	According to HealthCare.gov, this may be a good plan for people who...
Catastrophic^* Plan Level (Cost-Share) Catastrophic^*	$ Monthly Premium $	$$$$ Deductibles/ Out-of-Pocket Costs $$$$	If available, may be an affordable way to protect yourself from worst-case scenarios, like getting seriously sick or injured. Catastrophic plans cover the same 10 essential health benefits as other Marketplace plans. According to HealthCare.gov, this may be a good plan for people who... If available, may be an affordable way to protect yourself from worst-case scenarios, like getting seriously sick or injured. Catastrophic plans cover the same 10 essential health benefits as other Marketplace plans.

For catastrophic plans, the deductible is the same as the annual out-of-pocket (OOP) maximum ($10,600 for 2026), meaning once you pay your deductible, you've hit your OOP limit, and the plan covers 100% of other covered services for the year. 3 primary care visits and preventive care are covered before you hit your deductible.

Who can get a Catastrophic plan:

People under 30 years
People over 30 years and don't qualify for financial assistance on a Marketplace plan
Others who qualify for a hardship exemption or affordability exemption (based on Marketplace or job-based insurance being unaffordable)
For more information on who qualifies for a hardship or affordability exemption: https://www.healthcare.gov/health-coverage-exemptions/forms-how-to-apply/

Key features:	Bronze plans:	Catastrophic plans:
Availability	Available everywhere	Not available in all states or areas
Plan Options	Variety of choices	Limited (may only be 1-2 plans where available)
Monthly Premiums	Similar or may be lower cost than Catastrophic	Usually low premiums, but may be higher than Bronze
Services before deductible	Can cover several services before deductible is met	Offers 3 primary care visits during deductible period
Eligibility for the premium tax credit	Hospital Yes, can use the premium tax credit to lower your monthly costs, if you qualify	No, can’t use the premium tax credit if you qualify. You pay full price for the premium

Bronze plans:

Availability

Available everywhere

Plan Options

Variety of choices

Monthly Premiums

Similar or may be lower cost than Catastrophic

Services before deductible

Can cover several services before deductible is met

Eligibility for the premium tax credit

Hospital Yes, can use the premium tax credit to lower your monthly costs, if you qualify

Catastrophic plans:

Availability

Not available in all states or areas

Plan Options

Limited (may only be 1-2 plans where available)

Monthly Premiums

Usually low premiums, but may be higher than Bronze

Services before deductible

Offers 3 primary care visits during deductible period

Eligibility for the premium tax credit

No, can’t use the premium tax credit if you qualify. You pay full price for the premium

Learn more at: https://www.healthcare.gov/hsa-options/

Financial Help for Marketplace Plans

Premium Tax Credit

When you sign up for a Marketplace plan, you’ll find out if you qualify for a premium tax credit that lowers your premium.

The amount of your premium tax credit depends on your projected household income for 2026 that you put on your Marketplace application.
For information on who to include in your household and calculating your income:
- Who to include in your household: https://www.healthcare.gov/income-and-household-information/household-size/
- What to include as income: https://www.healthcare.gov/income-and-household-information/income/

Cost-Sharing Subsidies

If you qualify for cost-sharing subsidies, you must pick a plan in the Silver level to get these extra savings on out-of-pocket costs.
If you enroll in a plan at another level, you can still get a premium tax credit, but you won’t get the extra cost-sharing savings.
For more information on cost-sharing subsidies: 
https://www.healthcare.gov/lower-costs/save-on-out-of-pocket-costs/

How to Enroll

Buying a plan through the Marketplace is called “enrolling” in a plan

Where to Enroll

Website: https://www.healthcare.gov/ 
Local Help: To find local help with enrolling in a plan, visit: https://localhelp.healthcare.gov/

When to Enroll

There are two times when you can enroll in a Marketplace plan, called “enrollment periods:”
the Open Enrollment Period (OEP) and the Special Enrollment Period (SEP)

Open Enrollment Period

When Is It?

When Does Coverage Start?

The 2026 Marketplace Open Enrollment Period was from November 1st, 2025, to January 15th, 2026.

Please Note: States that run their own Marketplaces may have different Open Enrollment Periods.

The earliest plans start is January 1st, 2026.

When Is It?

When you lose coverage or have a life-changing event, you may qualify for a 60-day Special Enrollment Period.
Qualifying reasons include: loss of health insurance, moving, and changes in your household (e.g., marriage, birth or adoption of a child, divorce, or death of someone on your Marketplace plan)

When Does Coverage Start?

When your coverage starts depends on the date that you sign up, pick a plan, and submit your documents to the Marketplace. It is important to understand when your new plan will begin, to avoid gaps in coverage.

Employer-Sponsored Health Insurance Overview

Employer-sponsored insurance refers to health insurance offered by employers to their employees, dependents (children), and spouses, as an employee benefit.
Employer-sponsored health insurance is also called “Group Insurance” or a “Group Plan”

Employer Mandate

According to the Affordable Care Act: Employers with 50 or more full-time employees are mandated to offer health insurance that is affordable^* and provides minimum value^† to 95% of their full-time employees and their children up to the end of the month in which they turn age 26 or be subject to penalties.

About half of people in the U.S.
receive health insurance through an employer

^*Health insurance coverage is considered “affordable” if the employee’s share of the monthly premium for the lowest-cost plan offered by the employer is not more than a certain percentage of that employee’s household income (9.96% in 2026).
^† A plan provides “minimum value” if it pays at least 60% of the cost of covered services.

Employer-Sponsored Plans

An employer may offer one or more health insurance plans.
Employers choose the health insurance plan(s) they offer to their employees.
Your specific options, premiums, and out-of-pocket costs will depend on your employer’s plan(s).

Premiums for Employer-Sponsored Plans

Employers may pay the full cost of the monthly premiums or may ask employees to pay some of the cost of the premiums.

Fully-Insured vs. Self-Insured Plans

There are two types of employer-sponsored health plans:

Fully-Insured Plan (also called an insured plan or a funded plan): When an employer buys coverage for its employees from a private insurance company.
Self-Insured Plan (also called a self-funded plan): When an employer pays the medical bills of their employees directly. This approach is more commonly used by large employers and offers fewer consumer protections than funded plans.

How to Enroll

Your employer should give you information on how to enroll in an employer-sponsored health insurance plan.
If you have questions, ask whomever at your job deals with employee benefits for more information.

When to Enroll

There are three times when employees can enroll or make changes to their employer-sponsored health insurance plan:

When
You’re First Hired

Employees can usually enroll in their employer-sponsored health plan when they are first hired.
Employers are allowed to have up to a 90-day waiting period for coverage to begin

Open
Enrollment Period

Most employers have an Open Enrollment Period of 2-4 weeks one time each year when employees can enroll or make changes to an existing plan.
Open Enrollment Periods vary by employer.
Some employers have plans that start Jan 1, with their enrollment period being during the Fall.

Special
Enrollment Period

There are special circumstances, called “qualifying events” that qualify an employee for a Special Enrollment Period (SEP) where they may enroll in or make changes to a plan. The length of the SEP depends on the plan.
Qualifying events include, loss of eligibility from other coverage (for example, because of death or divorce), and certain life events such as marriage or the birth or adoption of a child.

COBRA Overview

COBRA is a federal law that allows eligible individuals to keep their existing employer-sponsored health insurance coverage after experiencing a “qualifying event.”

COBRA coverage must be substantially similar, if not the exact same coverage, that you had with your employer-sponsored plan.
It is important to remember that COBRA is not an actual health plan; it is the right to keep your employer-sponsored plan for an additional period of time.

The chart below lists the qualifying events that would entitle you to coverage under COBRA and the maximum length of time you can keep COBRA coverage:

COBRA Qualifying Events	Maximum Length of COBRA Coverage
Employment ends or hours reduced	18 months
When someone covered on a parent’s policy as a dependent child turns 26 and loses coverage	36 months
Covered employee enrolls in Medicare (spouse or a dependent child would be eligible for COBRA coverage)	36 months
Divorce or legal separation from covered employee (spouse or dependent child would be eligible for COBRA coverage)	36 months
Death of a covered employee (spouse or dependent child would be eligible for COBRA coverage)	36 months

For a closer look on COBRA, including cost and when it may be helpful, visit the “Health Insurance Options When Losing Employment” page (https://www.myhealthcarefinances.com/employment-disability#HealthInsuranceWhenLosingEmployment)

Commonly Asked Questions

Q. If my employer offers health insurance, do I have to take it?
A. NO. Employees can decline health insurance offered by employers

Q. Coverage through my employer is expensive and does not cover my health care providers, can I enroll in a Marketplace instead?
A. You can always shop for a plan in the Marketplace if you meet the eligibility criteria, but it is important to consider:

Employers may pay part of all of their plan’s premiums.
If you decline employer-sponsored health insurance that is affordable and provides minimum value you won’t qualify for financial help in the Marketplace.

For these reasons it is important to compare your total expected costs of employer-sponsored insurance and Marketplace plans.

For a closer look on how to pick employer or Marketplace plans, visit the “Tips for Picking an Employer or Marketplace Plan” page (https://www.myhealthcarefinances.com/health-insurance#PickAPlanEmployerMarketplace)

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Disclaimer: The information on this site is intended for U.S. residents only and is provided purely for educational purposes. Health, legal, regulatory, insurance, or financial related-information provided here is not comprehensive and is not intended to provide individual guidance or replace discussions with a healthcare provider, attorney, or other experts. All decisions must be made with your advisers considering your unique situation. © Triage Cancer & Pfizer Inc. 2026

Bronze plans:

Availability

Plan Options

Monthly Premiums

Services before deductible

Eligibility for the premium tax credit

Catastrophic plans:

Availability

Plan Options

Monthly Premiums

Services before deductible

Eligibility for the premium tax credit

When Is It?

When Is It?

When Does Coverage Start?

When You’re First Hired

Open Enrollment Period

Special Enrollment Period

When
You’re First Hired

Open
Enrollment Period

Special
Enrollment Period