Choosing a plan through the Affordable Care Act (ACA) marketplace can be a pivotal step in securing your health insurance coverage. This process involves understanding different plan options, comparing costs and benefits, and selecting a plan that best suits your healthcare needs and budget. Here’s a step-by-step guide to help navigate the ACA marketplace and make an informed decision:

Step 1: Understanding the Affordable Care Act

Enacted in 2010, the Affordable Care Act (ACA) expanded health insurance coverage to more than 20 million people by increasing benefits and lowering health insurance costs to make coverage more affordable. Also, the ACA expanded access to health insurance with the creation of a government health insurance marketplace (sometimes referred to as an exchange), which can be in the form of the federal marketplace in most states or state-administered marketplaces in some states. 

ACA plans (also known as Qualified Health Plans) are major medical insurance plans certified by the ACA Health Insurance Marketplace to be offered on the marketplace.  All ACA plans –

• Provide the 10 Essential Health Benefits
  • Emergency services
  • Hospitalization
  • Out-patient services
  • Maternity and newborn care
  • Mental health, behavioral health, and substance use disorder services
  • Prescription Drugs
  • Rehabilitative and habilitative services
  • Laboratory services
  • Pediatric services, including oral and vision care
  • Preventative and wellness services and chronic disease management
• Follow established limits on cost-sharing (such as deductibles, copayments and out-of-pocket maximum amounts)
• Provide coverage for pre-existing conditions
• Eliminate annual and lifetime dollar limits on health insurance coverage
• Provide 100% coverage for preventive care and cancer screening. 

ACA-compliant plans are also available off the government marketplace. You can purchase ACA-compliant health insurance and other types of insurance directly from the insurance company or through a private marketplace, such as eHealth. (eHealth offers consumers access to ACA plans on the marketplace as well as health insurance products offered outside the federal and state marketplaces.) 

In addition, off marketplace health insurance offerings include non-
ACA compliant medical plans, which do not include all of the benefits and consumer protections of ACA plans as well as insurance that is not regulated by the ACA, such as indemnity plans and short-term insurance policies.  

Step 2: Assess your healthcare needs

Evaluating your and your family’s healthcare needs is crucial in selecting an ACA plan that aligns with your requirements. Consider factors such as the frequency of doctor visits, any chronic conditions, prescription medications, and the potential need for specialist care or surgeries. For families, think about pediatric care for children, including immunizations and regular check-ups. Women’s health services, such as prenatal and maternity care, should also be considered if relevant. Reflect on any anticipated changes in health needs in the upcoming year, like planned surgeries or treatments. Assessing these aspects will guide you in choosing a plan with the right level of coverage and benefits.

Step 3: Understanding the types of ACA plans

In the third step of choosing an ACA plan, it’s important to understand the different categories of plans available. These categories, often referred to as “metal tiers,” include Bronze, Silver, Gold, and Platinum. Each tier represents a different level of cost-sharing between you and the insurance provider. Understanding these categories and how they align with your healthcare needs and financial situation is key to selecting the right plan for you or your family. This step involves balancing the monthly premium costs with the potential out-of-pocket expenses you might incur for healthcare services.

Preferred Provider Organization plans (PPOs)

Preferred Provider Organization plans, also called PPOs, are one of the most popular plan types for individuals and families. PPOs allow you to visit whatever in-network health care provider you’d like without requiring a referral from a primary care provider.

In-network care will be covered at a higher benefit level than any care you receive out-of-network.

You can expect PPO plans to require you to pay an annual deductible before the insurance company begins paying its portion for most services. Additionally, you may also have a co-pay (according to eHealth surveys, co-pays are usually around $10-$30) or coinsurance that you have to pay for certain health care services.

A PPO plan may be the right ACA plan for you if:

• You want to freedom to choose almost any medical facility or provider for your needs
• You want some coverage if you choose to go out-of-network
• You don’t want to have to receive a referral first from your primary care provider in order to see a specialist

Point-of-service plans (POS)

A Point of Service Plan, or POS, has some qualities of an HMO and PPO with benefit levels depending on if you receive care in or out-of-network. You can think of a POS plan as a HMO/PPO hybrid.

Similar to an HMO plan, with a POS plan you will have to designate a PCP who will make referrals to in-network specialists when you require it. Typically services received through your PCP are typically not subject to a deductible. Preventive care services are covered at the PCP office visit copayment.

Similar to a PPO plan, you may receive care from providers who are out of your provider network, but your out-of-pocket costs will be greater. You will likely pay a higher co-pay, coinsurance, or deductible for out-of-network services than applies to in-network services.

• A POS plan may be the right ACA plan for you if:
• You are willing to coordinate your care through your designated primary care physician
• Your preferred doctor participates within the plan network

Health Maintenance Organization plans (HMO)

HMO, or Health Maintenance Organization, plans offer a wide range of healthcare services through a network of providers who agree to supply these services to members. You’re likely to have coverage for a broad range of preventative healthcare services than you would through another plan.

As of 2018, HMOs have emerged as the most popular ACA plan among eHealth customers. According to the KFF, 21,446,150 Americans selected marketplace plan in 2024.

You will be required to choose a primary care physician (PCP) who will take care of most of your health care needs. Your PCP will need to refer you to a specialist if you decide you need to consult with one.

While HMOs typically have lower out of pocket costs, you may be required to pay a deductible before your HMO begins paying its portion for covered health services.  Your copays will likely be reasonable, and for services such as doctor office visits, you may pay a copayment of $20 – $35 and the HMO will pay the rest of the eligible charge. No deductible may apply to the doctor visit. Keep in mind that with an HMO you will likely have no coverage for non-emergency care you receive out-of-network or for services you receive without a proper referral from your PCP.

A HMO plan may be the right ACA plan for you if:

• You’re shopping for an ACA plan with a low monthly premium
• You want an ACA plan with little or no deductible 
• Your typical care is preventative care services

Exclusive Provider Organization plans

With an Exclusive Provider Organization plan, or EPO, you exclusively use the healthcare providers – this includes doctors, specialists, and hospitals – within the plan network. You don’t need a referral, but if you pay the full medical bill if you out outside the plan’s provider network for non-emergent care that the plan hasn’t authorized coverage before you receive it.  

An EPO plan may be the right ACA plan for you if:

• You do not want to have to get a referral to see a specialist
• Your preferred providers are in-network
• You want to receive a lower monthly premium than what you would typically get with an HMO or a PPO plan

You can start shopping for a health insurance plan that fits your budgetary and coverage needs at any point in the year. However, you can only enroll in an ACA-compliant plan during the annual open enrollment period – which typically runs from November 1st through December 15th in most states – or during a special enrollment period. 

eHealth’s intuitive site and license health insurance agents can  help you compare your health insurance plan options to find the plan that suits you best. Visit our Individual & Family health insurance page today to see the ACA compliant plans that are available. 

Step 4: Consider budget for health insurance

In step four, your budget plays a crucial role in determining the most suitable ACA plan. When considering your budget, think about not only the monthly premium but also the overall cost, including deductibles, copayments, and out-of-pocket maximums.

• If You Need to Save Money Upfront: Opt for a Bronze or Silver plan. Bronze plans typically have the lowest monthly premiums but higher out-of-pocket costs when you need care. Silver plans balance moderate premiums with lower costs when accessing healthcare services and may offer additional cost-sharing reductions if you qualify based on income.
• If You Have a Larger Budget: Gold or Platinum plans may be more appropriate. These plans have higher monthly premiums but significantly lower out-of-pocket costs for medical services. They are ideal if you anticipate needing frequent healthcare services, as they minimize the cost per visit or treatment.

Choosing a plan that aligns with your financial capacity ensures that you can comfortably afford your health insurance while meeting your healthcare needs. Balancing the premium costs with anticipated healthcare expenses is key to making a cost-effective decision.

Step 5: Research in-network providers

The fifth step in choosing an ACA plan involves researching in-network providers to ensure your preferred doctors, hospitals, and healthcare facilities are covered by the plan. The choice of in-network providers can significantly impact both your access to healthcare and the costs you incur.

• Plans for In-Network Only Providers: HMO (Health Maintenance Organization) plans typically require you to use doctors and hospitals within their network, except in emergencies. These plans are a good choice if you have established relationships with providers in the network or if you value lower premiums and are comfortable with limited provider choices.
• Plans with Flexible Out-of-Network Options: PPO (Preferred Provider Organization) plans offer more flexibility, allowing you to see providers both in and out of the network, though seeing out-of-network providers usually involves higher costs. These plans are ideal if you need or prefer a broader choice of healthcare providers, including specialists not available in-network.

Understanding your plan’s network and its alignment with your healthcare provider preferences is crucial. It can prevent unexpected expenses and ensure that you have access to the care you need without incurring higher out-of-pocket costs for out-of-network services.

Step 6: Consider prescription drug needs

In step six, evaluating your prescription drug needs is essential in selecting the right ACA plan. Prescription drug coverage can vary significantly between plans, so it’s important to choose one that aligns with your medication requirements.

• For Those with Regular Prescription Needs: If you or your family members regularly require prescription medications, especially expensive or brand-name drugs, consider a plan that offers comprehensive prescription drug coverage. Gold and Platinum plans typically provide better coverage for a wider range of medications with lower copayments, making them suitable for individuals with significant prescription needs.
• For Those with Minimal Prescription Needs: If you rarely need prescription drugs, a Bronze or Silver plan might be more cost-effective. These plans usually cover basic prescription needs but may have higher copayments and a more limited formulary. They are a good option for those who want to balance lower premiums with essential drug coverage.

Reviewing the plan’s formulary, which is the list of covered medications, and understanding the cost-sharing details for prescriptions (like copayments and deductibles) will help ensure your medication needs are adequately covered without incurring excessive costs.

Step 7: Leveraging cost assistance programs

The seventh step in choosing an ACA plan involves exploring and leveraging cost assistance programs that can make health insurance more affordable. One of the key programs under the ACA is premium subsidies, which are designed to help lower the cost of health insurance for individuals and families with income within certain thresholds.

• Premium Subsidies: These subsidies reduce the monthly premium of your health insurance plan and are available to individuals and families with incomes between 100% and 400% of the federal poverty level. The exact amount of the subsidy depends on your income, the cost of insurance plans in your area, and the benchmark plan cost.
• Determining Eligibility: To determine your eligibility for these subsidies, you can use the Health Insurance Marketplace calculator or consult with a healthcare navigator. When applying for an ACA plan, you’ll need to provide income information, which the Marketplace uses to calculate your subsidy amount.

These cost assistance programs are crucial for making health insurance more accessible and affordable, particularly for those with limited income. By taking advantage of these subsidies, eligible individuals can significantly reduce their healthcare expenses while ensuring they have the coverage they need.

Step 8: Navigating the ACA marketplaces

Navigating the ACA marketplace is the final step in choosing your health insurance plan. The marketplace, accessible online, is designed to simplify the process of comparing and purchasing health insurance plans. Here are some tips on effectively using the marketplace and online tools, including platforms like eHealth:

1. Accessing the Marketplace: Visit the official Health Insurance Marketplace at Healthcare.gov or your state’s marketplace website if your state runs its own exchange.
2. Create an Account: Start by creating an account. You’ll need to provide some basic information about yourself and your household.
3. Utilize Comparison Tools: Use the website’s comparison tools to review different plans side-by-side. Look at premiums, deductibles, out-of-pocket maximums, and covered benefits.
4. Filter Based on Preferences: You can filter plans based on your preferences for premiums, deductibles, type of plan (like HMO or PPO), and insurance company.
5. Check Eligibility for Subsidies: Use the online tools to check your eligibility for subsidies and see how much you can save on premiums.
6. Consult eHealth: Platforms like eHealth offer an additional resource for comparing plans. eHealth provides a user-friendly interface to compare plans from different insurers, including those outside the ACA marketplace, and offers support and advice from licensed insurance agents. To speak to one of eHealth’s licensed insurance agents and find the right plan for your needs, begin comparing plans with your zip code.
7. Seek Assistance if Needed: If you need help, you can contact the marketplace call center or consult with a trained navigator or broker in your area.

By methodically using these online resources and tools, you can make an informed decision about your health insurance plan, ensuring that it meets your healthcare needs and financial situation.

Step 9: Apply for an ACA plan

Applying for an ACA plan is the final step in securing your health insurance. Here’s a brief guide to the application process, emphasizing the importance of accuracy and completeness:

1. Gather Necessary Information: Before you start, gather all required information including your Social Security number, income details, and information about any current health insurance.
2. Access the Marketplace: Go to the Health Insurance Marketplace at Healthcare.gov or your state’s marketplace website.
3. Fill Out the Application: Complete the application form. Be thorough and accurate, especially with income and household information, as this affects your eligibility for subsidies and plan choices.
4. Review Plan Options: Once you submit your application, you’ll see the plans you’re eligible for. Review these options carefully, considering premiums, deductibles, out-of-pocket costs, and coverage details.
5. Select a Plan: Choose the plan that best fits your healthcare needs and budget. Double-check the plan’s network to ensure your preferred healthcare providers and hospitals are included.
6. Complete Enrollment: After selecting a plan, complete the enrollment process by following the instructions provided. Ensure all information is correct before finalizing.
7. Check for Confirmation: You should receive confirmation of your enrollment from the marketplace and a welcome packet from your new insurance provider.

Accuracy and completeness in your application are crucial to ensure you get the right coverage and avoid issues down the line. Take your time to review all details before submitting your application and choosing your plan.

Step 10: Enrollment periods and deadline reminders

Understanding and keeping track of key enrollment periods is vital in securing health insurance through the ACA. Here are the important periods to note:

• Open Enrollment Period: The primary time to enroll in or change your ACA health insurance plan is during the open enrollment period, which typically runs from November 1st to December 15th each year. This period applies to most states, but some states with their own marketplaces may have different dates.  Also, the government may adjust the open enrollment period dates each year.
• Special Enrollment Periods: If you experience qualifying life events like marriage, birth of a child, or loss of other health coverage, you may be eligible for a special enrollment period. This allows you to enroll outside the standard open enrollment period.
• Deadlines: Be aware of deadlines. The end of the open enrollment period is crucial, and missing it could mean having to wait until the next year to get coverage, barring special circumstances.

For specific information and deadlines, including variations in the open enrollment by state, it’s important to check the Health Insurance Marketplace or your state’s marketplace website. Staying informed about these enrollment periods and deadlines ensures you don’t miss the opportunity to enroll in or change your health insurance plan.