To qualify for subsidies and tax credits on the ACA Marketplace, your household income generally needs to be between 100% and 400% of the federal poverty level, and eligibility is also based on family size and other factors. These financial aids can significantly lower your monthly premiums and out-of-pocket costs.

The ACA Marketplace offers four metal categories of health insurance plans: Bronze, Silver, Gold, and Platinum. Bronze plans have the lowest monthly premiums but the highest out-of-pocket costs, while Platinum plans have the highest premiums but the lowest costs when you need care. Silver and Gold plans fall in between, with Silver plans often eligible for additional cost-sharing reductions. Choosing a metal category impacts your monthly premiums, deductibles, copays, and overall out-of-pocket costs, so it’s important to balance your healthcare needs and budget.

HMO (Health Maintenance Organization) plans require you to use a network of doctors and hospitals, need referrals to see specialists, and generally have lower premiums but less flexibility. PPO (Preferred Provider Organization) plans offer more flexibility with a larger network and no referral requirements, but they come with higher premiums and out-of-pocket costs. POS (Point-of-Service) plans combine features of HMOs and PPOs, requiring referrals for specialists but offering some out-of-network coverage, balancing flexibility and cost.

A deductible is the amount you must pay out-of-pocket for covered healthcare services before your insurance starts to pay. The maximum out-of-pocket (MOOP) is the most you’ll pay for covered services in a plan year; after reaching this limit, your insurance covers 100% of remaining costs. Copays are fixed amounts you pay for specific services, like doctor visits or prescriptions, on top of any deductible or coinsurance.

A special enrollment period allows you to enroll in a Marketplace plan outside the standard open enrollment if you experience a qualifying life event such as losing other coverage, getting married, or having a baby. You typically have 60 days from the event to enroll and may need to provide documentation to verify the event. It’s crucial to act quickly to avoid gaps in your health coverage.

Estimating your annual income is crucial for determining your eligibility for subsidies and tax credits on the ACA Marketplace. To calculate your total annual income, include wages, salaries, tips, self-employment income, unemployment compensation, and other taxable income. Accurately reporting your income helps ensure you receive the correct level of financial assistance, so make your best estimate based on your expected earnings for the year.

Whether you can keep your current doctor depends on whether they are in the network of the ACA Marketplace plan you choose. It’s important to check the plan’s provider network before enrolling to ensure your preferred doctors and hospitals are included.

All ACA Marketplace plans are required to cover prescription drugs as part of their essential health benefits. You can find information about which specific medications are covered by checking your insurer’s website, reviewing the Summary of Benefits and Coverage, or contacting the insurer directly. If a particular medication isn’t covered, you may be able to use the drug exceptions process to get it approved for coverage.