Health Plan FAQ’s

From 2021 through 2025, the American Rescue Plan Act and the Inflation Reduction Act made Marketplace coverage much more affordable. Under those laws, no one paid more than 8.5% of household income for a benchmark plan, and there was no upper income limit for help. Congress didn't extend these enhanced subsidies, so they expired on December 31, 2025. The original ACA subsidy rules now apply for both 2026 and 2027.

What this means for you:

• The "subsidy cliff" is back. Households earning above 400% of the Federal Poverty Level get no premium help at all. For example, a 60-year-old couple earning $90,000 can face premiums of $1,500–$2,000 a month or more with no subsidy.
• Middle-income and older enrollees pay more. Many people lost part or all their subsidy. Adults aged 50–64 are hit hardest because their full-price premiums are the highest.
• Lower-income enrollees still get strong help. Subsidies remain substantial for people near the poverty level.
• Many enrollees are trading down. People are moving to Bronze plans, narrower networks, or non-ACA options such as short-term plans or private group plans.

Open enrollment for 2027 plans on HealthCare.gov runs November 1, 2026 through January 15, 2027.

States that run their own exchanges may set different dates, and some run into late January. Find your state's marketplace.

Outside open enrollment, you need a Qualifying Life Event (QLE) to enroll. Examples include losing other coverage, getting married, having a baby, or moving. A QLE opens a Special Enrollment Period (SEP), which generally lasts 60 days from the event. SEP coverage usually starts the first day of the month after you pick a plan. A newborn or newly adopted child can be covered back to the date of birth or adoption.

When a licensed agent helps you with a Marketplace application, federal rules require three separate steps. Each one protects you in a different way.

Step 1: Agent Authorization (new for 2027)

Starting October 12, 2026, CMS requires you to authorize your agent before they can access, update, or submit your Marketplace application. Here's how it works:

• You'll get a request by text or email. It comes from HealthSherpa, the secure platform we use. Texts come from (628) 222-2905, and emails come from no_reply@healthsherpa.com. Open it on your own phone or computer.
• You confirm that you want us as your agent. The link expires after 15 minutes, but you can refresh it yourself if it does.
• You may need to verify your identity. CMS requires this for applications it considers higher risk. Examples include people new to the Marketplace or to their state, people switching agents, and people paying $30 a month or less after their subsidy.
• Only the primary contact authorizes. Other household members on your application don't need to.
• Authorization lasts one plan year. You'll need to authorize us again each year, including at renewal.
• Only one agent can be authorized at a time. If you authorize a different agent, that replaces your earlier authorization.

If you get an authorization request you weren't expecting, don't complete it. Call us or the Marketplace instead.

Step 2: Consumer Consent

Authorization gives us access to your application. Consent is your permission for us to actually help you. That help includes searching for your existing application, checking your coverage, and applying or making changes on your behalf. You can give consent in writing, electronically, or on a recorded call. The record shows:

• the date
• your name
• our name
• what you're allowing us to do, and for how long
• how to withdraw your consent, which you can do at any time

Step 3: Eligibility Application Review

Before we submit a new application, an update, or a plan selection, you must:

• review your application information and plan choice
• confirm that everything is accurate
• have the attestations at the end of the application explained to you

We're required to keep records of your consent and your review for at least 10 years.

After you apply: Marketplace verification

When you sign your application, you are attesting under penalty of perjury that the information is true. The Marketplace checks it against federal data sources, including the IRS, the Social Security Administration, and the Department of Homeland Security.

If something doesn't match, you'll get a notice asking for documents. Deadlines are:

• 30 days for proof of a Special Enrollment Period event
• 90–95 days for income, citizenship, or immigration status

Missing a deadline can cost you your subsidy or your coverage. Knowingly giving false information can result in significant federal penalties.

Protect yourself:

• Report changes in income or household promptly.
• Never share your HealthCare.gov username or password. We will never ask for it.
• If you believe someone changed your application without permission, call the Marketplace at 1-800-318-2596 (TTY: 1-855-889-4325).

Call us on 786-970-0740 (Cell) with any questions.

Loss of coverage: You must submit proof, generally within 30 days of choosing a plan. Your enrollment may be on hold until the proof is verified.

Most other events (marriage, a move, a birth): On HealthCare.gov, you can currently self-attest without sending documents up front. However, enrollments can be reviewed later, and coverage can be canceled retroactively if your eligibility can't be confirmed. Always keep documentation of your life event.

Every ACA plan must cover ten categories of Essential Health Benefits:

• ambulatory (outpatient) care
• emergency services
• hospitalization
• maternity and newborn care
• mental health and substance use services
• prescription drugs
• rehabilitative and habilitative services
• lab services
• preventive and wellness care, including chronic disease management
• pediatric care, including dental and vision for children under 19

Pediatric dental must be offered to you, either built into the plan or as a separate dental plan, but you aren't required to buy it. Adult dental and vision aren't essential benefits, though some plans offer them as add-ons.

A Qualified Health Plan (QHP) covers all these benefits and meets additional federal standards:

• limits on out-of-pocket costs
• no annual or lifetime dollar limits on essential benefits
• no pre-existing condition exclusions
• adequate provider networks
• nondiscrimination protections

Yes. ACA plans can't deny you, exclude pre-existing conditions, or charge more based on your health. Premiums can vary only by:

• age
• tobacco use
• family size
• where you live

All Qualified Health Plans use networks of contracted doctors, hospitals, and pharmacies. Today's networks are often smaller than they were before the ACA. The main types are:

• HMO: You must use in-network providers except in emergencies. Some HMOs require referrals to see specialists.
• EPO: In-network providers only, except in emergencies, but no referrals are needed.
• PPO: Covers both in-network and out-of-network care, with no referrals needed. PPOs usually have higher premiums and are less widely available.
• POS: Allows out-of-network care but requires a referral to see a specialist.

If a particular doctor matters to you, confirm they're in the plan's network before you enroll. Networks can change each year, and providers can leave a network during the year.

An exchange is where you compare plans, find out whether you qualify for financial help, and enroll. Some states use the federal HealthCare.gov. Others run their own exchange, such as Covered California or Pennie in Pennsylvania.
You can check which type your state uses.

Premium tax credits and Cost Sharing Reductions are available only on-exchange. On-exchange enrollment includes going through a licensed agent using a CMS-approved enrollment platform (see FAQ 20). If you qualify for help, buying off-exchange could cost you thousands of dollars a year.

If you don't qualify for help, off-exchange plans are generally priced the same as identical on-exchange plans. One exception: in many states, off-exchange Silver plans can be cheaper. Insurers often build Cost Sharing Reduction costs into on-exchange Silver premiums only, a practice called "silver loading."

Exchange plans come in four metal levels. The percentage shows roughly how much of average costs the plan pays:

Plans at the same level can still differ. For example, one may have a lower deductible but higher copays than another.

• Deductible: What you pay for covered care before the plan starts paying.
• Copay: A fixed dollar amount you pay for a service or prescription.
• Coinsurance: A percentage of the cost you pay after meeting your deductible.
• Out-of-pocket maximum: The most you'll pay in a year for covered in-network care. Deductibles, copays, and coinsurance count toward it. Premiums and out-of-network care do not. Once you reach it, the plan pays 100% of covered in-network costs for the rest of the year.

The federal government caps out-of-pocket maximums each year. Many plans set lower limits.

You're considered a tobacco user if you've used tobacco four or more times a week, on average, during the past six months. Insurers may treat vaping differently, so check with your carrier.

Insurers can charge tobacco users up to 50% more. A few things to know:

• Some states, plus DC, limit or ban this surcharge, so check your state's rules.
• Subsidies don't apply to the surcharge, so you pay it in full yourself.
• All ACA plans cover programs to help you quit at no cost.

Losing job-based coverage opens a 60-day Special Enrollment Period. That window runs at the same time as your COBRA election period, so you can take the full 60 days to compare your options.

Important: If you elect COBRA and later drop it or stop paying, that does not open a new enrollment period. Outside open enrollment, you can switch from COBRA to an ACA plan only if:

• your COBRA coverage runs out
• your former employer stops contributing to its cost
• you're still within 60 days of losing your job-based coverage

ACA plans are often cheaper than COBRA, especially if you qualify for a subsidy. Subsidies can't be used toward COBRA. Learn more.

The Federal Poverty Level (FPL) determines whether you qualify for financial help. Subsidies use the FPL figures published the year before. For example, the 2026 FPL figures apply to 2027 plans.

2027 Subsidy Eligibility [Based On 2026 Federal Poverty Levels (FPL)]

Note: Household size means the total number of people in the household for tax purposes, regardless of how many are enrolling in an ACA plan. Separate, higher FPL guidelines apply in Alaska and Hawaii.

Subsidy (Advance Premium Tax Credit)

The ACA provides subsidies to help individuals and families pay their monthly health i

You may qualify for a premium tax credit if all of these apply:

• Your household income (MAGI) is between 100% and 400% of FPL. In Medicaid expansion states, people below 138% of FPL are generally directed to Medicaid instead. Florida hasn't expanded Medicaid.
• You enroll through an exchange.
• You aren't eligible for affordable employer coverage, Medicare, or Medicaid.

For 2027, that income range is $15,960–$63,840 for one person. Earning even one dollar over 400% means no subsidy. [2026 and 2027 FPL charts]

What is MAGI?

Modified Adjusted Gross Income can be higher than the adjusted gross income on your tax return. For example, it includes all your Social Security benefits, even the non-taxable portion. How to calculate MAGI.

Employer coverage and affordability: You may qualify for a subsidy despite an offer of employer coverage if that coverage is considered unaffordable or doesn't provide minimum value. Coverage is unaffordable if:

• the employee's cost for self-only coverage is more than 10.22% of household income in 2027, or
• the family's cost for family coverage is more than that same percentage.

Since 2023, affordability has been judged separately for the employee and for family members, which fixed the old "family glitch."

For employers, self-only coverage costing no more than $129.90/month in 2026 automatically counts as affordable under the FPL safe harbor. That figure is about $135.93/month for 2027 calendar-year plans.

Premium tax credits lower your monthly premium. You can have the credit paid directly to your insurer each month, or claim it when you file your taxes.

Cost Sharing Reductions (CSRs) lower your deductible, copays, and out-of-pocket maximum. They're available only on Silver plans bought on-exchange, for households earning between 100% and 250% of FPL. Depending on your income, a CSR raises the share of costs a Silver plan pays from 70% to 73%, 87%, or 94%.

• Level 6 (strongest reduction): MAGI between 100/138% and 150% FPL
• Level 5: MAGI between 150% and 200% FPL
• Level 4: MAGI between 200% and 250% FPL

A CSR Silver plan can have a premium like a Bronze plan's, with a far lower deductible. For example, the average 2026 Bronze deductible is about $7,186, while a 94% CSR Silver plan's deductible can be under $100. HealthCare.gov no longer automatically moves eligible Bronze enrollees into Silver plans, so be sure to compare Silver plans yourself.

After you apply, save your eligibility notice. It shows your subsidy, any CSR, and any documents you need to submit. Typical deadlines:

• 30 days for proof of a qualifying life event
• 90 days for income verification
• about 95 days for proof of citizenship or immigration status

Missing a deadline can cost you your subsidy or your coverage. Upload documents to your account, or mail copies (never originals) with your application ID on every page.

Starting with 2026 coverage, there's no limit on repayment. If you underestimate your income, you must repay the full excess subsidy when you file your taxes.

There is one exception. If your actual income ends up below 100% of FPL, you generally won't have to repay, if you estimated your income in good faith (CMS FAQ).

To protect yourself:

• Report income and household changes promptly.
• Consider taking less than your full subsidy up front.

Coming changes:

• January 1, 2027: Subsidies will be limited to U.S. citizens, green card holders, certain Cuban/Haitian entrants, and Compact of Free Association migrants. Other lawfully present immigrants can still buy coverage, but without a subsidy.
• Plan year 2028: Automatic re-enrollment with subsidies ends. You'll need to verify your income and actively re-enroll each fall.

A catastrophic plan covers all essential benefits but has a very high deductible and lower premiums. The plan covers three primary care visits a year and all preventive care before you meet the deductible. After that, it pays 100%. The deductible equals the out-of-pocket maximum: $10,600 in 2026 and $12,000 in 2027.

Who qualifies:

• anyone under 30
• people 30 or older who first get an exemption certificate from the Marketplace, either a hardship exemption (such as homelessness, eviction, or bankruptcy) or an affordability exemption (the lowest-cost coverage available would cost too much compared with your income). Having an income below or above the subsidy range does not by itself qualify you for 2027.

You can't use subsidies with a catastrophic plan. If you qualify for a subsidy, a subsidized Bronze plan usually costs less.

New for 2027: Insurers may offer multi-year catastrophic plans with benefits locked in for up to 10 years. Premiums still adjust each year. Catastrophic plans aren't offered in every area.

Several recent federal rule changes are being challenged in court, and some provisions have been blocked for now. These challenges do not affect 2027 open enrollment dates (November 1, 2026 – January 15, 2027). We'll update this page if any outcome affects your coverage.

You must pay your first premium, called the "binder payment," before your coverage start date. Pay the insurance company directly, not HealthCare.gov. Automatic bank payments are recommended.

Grace periods: If you receive a premium tax credit, you have a 3-month grace period for later payments. Otherwise, the grace period is set by your carrier and state, often 30 days. Missed payments must be caught up during the grace period to keep your coverage.

There's no federal penalty. California, DC, Massachusetts, New Jersey, and Rhode Island have their own state penalties, so check with your tax preparer if you live in one of them. Vermont requires coverage but has no penalty.

A web brokerage is a CMS-approved platform that lets a licensed agent complete your Marketplace application and enrollment securely, without you logging into HealthCare.gov. We use HealthSherpa, the most widely used Enhanced Direct Enrollment (EDE) platform. It connects directly and securely to the federal Marketplace, much like your bank's app connects to your bank.

Through HealthSherpa, we can:

• complete your application
• compare and enroll you in plans
• report income or household changes
• upload documents and download your notices

EDE platforms must pass strict independent security and privacy audits and be re-certified every year.

>We will never ask for your HealthCare.gov username or password. See FAQ 3 for how authorization, consent, and application review protect you.