To get health insurance in the United States, you generally go through one of four doors: a job that offers coverage, Medicare if you’re 65 or older or on long-term disability, Medicaid or CHIP if your income is low, or the federal Health Insurance Marketplace at HealthCare.gov for everyone else. Which door is yours depends on your age, your household income, and whether an employer offers you a plan you can afford. Picking the right one matters, because the wrong choice can cost thousands of dollars a year or leave you with a coverage gap you didn’t need to have.
Coverage Through a Job
If you work for an employer that offers health benefits, that is almost always your starting point. Premiums come out of your paycheck before taxes, which lowers both your taxable income and your real out-of-pocket cost compared to buying the same plan yourself. Your employer typically pays a large share of the premium too.
Having a job offer also affects your Marketplace options. Under ACA rules, employer coverage counts as “affordable” if the cheapest self-only plan costs no more than a set percentage of your household income. For the 2026 plan year, that threshold is 9.96%. If your employer’s self-only premium is higher than that share of your income, the coverage is considered unaffordable, and you can shop on the Marketplace with premium tax credits instead.1Internal Revenue Service. Questions and Answers on Employer Shared Responsibility Provisions Under the Affordable Care Act
When you start a new job, your employer will give you a window of at least 30 days to enroll. Miss that window and you’ll usually wait until the company’s annual open enrollment unless a qualifying life event opens a new one.
Coverage Through HealthCare.gov
If your job doesn’t offer insurance, offers coverage that fails the affordability test, or you’re self-employed or between jobs, the Marketplace is the main channel. You apply through HealthCare.gov or your state’s exchange, answer questions about your household and income, and the system shows which plans are available where you live and any subsidies you qualify for.
Marketplace plans have to cover a defined set of essential benefits: hospitalization, prescription drugs, maternity care, mental health, and preventive care at no extra cost. Insurers cannot deny you coverage or charge more for a pre-existing condition. For 2026, no plan can require you to pay more than $10,600 out of pocket as an individual, or $21,200 as a family, before the insurer picks up the rest.
Plans come in four metal tiers that describe how costs are split with the insurer, on average: Bronze (plan pays about 60%), Silver (about 70%), Gold (about 80%), and Platinum (about 90%). Lower tiers have cheaper premiums and higher deductibles; higher tiers reverse that. Silver is the only tier eligible for extra cost-sharing reductions, which can push the plan’s share as high as 94% if your income qualifies. People under 30, or anyone with a hardship exemption, can also buy a Catastrophic plan with very low premiums and very high deductibles, though those plans don’t qualify for premium subsidies.2HealthCare.gov. Health Plan Categories: Bronze, Silver, Gold, and Platinum
Premium Tax Credits
Premium tax credits are what make Marketplace coverage affordable for most people who use it. For 2026, the credits are available to households with income between 100% and 400% of the federal poverty level who enroll through the Marketplace and don’t have access to affordable employer coverage or a government program. For a single person in 2026, 400% of poverty is about $63,840; for a family of four, it’s $132,000.3HHS ASPE. 2026 Poverty Guidelines The enhanced subsidies that applied from 2021 through 2025 have expired, so households above 400% of poverty no longer get premium help.
Most people take the credit in advance, applied directly to their monthly premium. You’re estimating your income for the year when you do this, and if your actual income ends up higher, you’ll owe back some or all of the excess when you file taxes. Starting with the 2026 plan year, there is no cap on the amount of excess advance credit you may have to repay.4CMS Agent and Broker FAQ. Are There Limits to How Much Excess Advance Payments of the Premium Tax Credit Consumers Must Pay Back If your income is volatile, underestimate carefully. If your income or household size changes mid-year, report it to the Marketplace as soon as it happens so your subsidy stays accurate.5HealthCare.gov. Reporting Income, Household, and Other Changes
At tax time, you reconcile the credit by filing IRS Form 8962. If any advance payments were made on your behalf, filing this form is mandatory. Skipping it can delay your refund and cause problems with next year’s enrollment.6Internal Revenue Service. 2025 Instructions for Form 8962 – Premium Tax Credit
Medicaid and CHIP
Medicaid is jointly funded by the federal and state governments and covers people with limited income. In states that adopted the ACA’s Medicaid expansion, adults under 65 generally qualify with household income up to 138% of the federal poverty level. For a single person in 2026, that’s roughly $22,025; for a family of four, about $45,540.3HHS ASPE. 2026 Poverty Guidelines In states that did not expand, eligibility is much tighter, and many low-income adults without children fall into a coverage gap: too much income for traditional Medicaid, too little to qualify for Marketplace subsidies.
The Children’s Health Insurance Program (CHIP) covers kids under 19 in families that earn too much for Medicaid but can’t afford private coverage. Income limits vary by state, running anywhere from 170% to 400% of the federal poverty level.7Medicaid.gov. CHIP Eligibility and Enrollment
Medicaid and CHIP have no enrollment season. You can apply any day of the year, and coverage often begins immediately on approval. If you start a Marketplace application and your income looks low enough, HealthCare.gov will route your file to your state Medicaid agency automatically.
Medicare
Medicare is the federal program for people 65 and older, as well as younger people who have received Social Security disability benefits for at least 24 months or who have end-stage renal disease.8Office of the Law Revision Counsel. 42 USC Chapter 7, Subchapter XVIII: Health Insurance for Aged and Disabled Part A covers hospital stays and is usually premium-free if you or your spouse paid Medicare taxes for at least 10 years. Part B covers doctor visits, outpatient care, and preventive services; the standard Part B premium for 2026 is $202.90 per month.9Centers for Medicare & Medicaid Services. 2026 Medicare Parts A and B Premiums and Deductibles
Your initial enrollment window is seven months long: it begins three months before the month you turn 65, includes your birthday month, and ends three months after. Miss it and you’ll pay a late-enrollment penalty that adds 10% to your Part B premium for every full year you could have signed up but didn’t, and that penalty generally lasts for the rest of your life.10Medicare.gov. Avoid Late Enrollment Penalties A separate General Enrollment Period runs January 1 through March 31 each year for people who missed their initial window, but the penalty still applies.
When You Can Sign Up
For Marketplace plans, Open Enrollment runs from November 1 through January 15. Pick a plan by December 15 and coverage starts January 1; enroll between December 16 and January 15 and coverage starts February 1.11Centers for Medicare & Medicaid Services. Marketplace 2025 Open Enrollment Fact Sheet Outside that window you generally cannot buy a Marketplace plan unless a qualifying life event opens a Special Enrollment Period.
Special Enrollment Periods give you 60 days from the triggering event to sign up.12HealthCare.gov. Special Enrollment Period The common triggers:
- Losing existing coverage: a layoff, an employer dropping its plan, aging off a parent’s plan at 26, or losing Medicaid eligibility. You can enroll up to 60 days before or after the loss.
- Household changes: marriage, the birth or adoption of a child, or divorce with loss of coverage. For a new baby, coverage can be backdated to the date of birth.
- Moving to a new ZIP code or county with different plans available, as long as you had qualifying coverage for at least one day in the 60 days before the move. Moving for medical treatment or vacation doesn’t count.
You can also qualify under exceptional circumstances, such as a FEMA-declared disaster or an error by the Marketplace or an insurance company that caused you to miss a deadline.13Centers for Medicare & Medicaid Services. Special Enrollment Periods Job Aid You’ll need to document whatever triggered the window: a letter from your former insurer, a COBRA notice, or a letter from your employer showing when coverage ended, with your name, the end date, and official letterhead.14Centers for Medicare & Medicaid Services. Special Enrollment Period Verification Issue Checklist Miss the 60 days and you’ll usually wait until the next Open Enrollment, so don’t sit on it.
What You Need to Apply
The Marketplace application asks for Social Security numbers for everyone in your household, including people who aren’t applying for coverage. These are used for identity verification and to check income against government records.15HealthCare.gov. Get Ready to Apply for or Re-Enroll in Your Health Insurance Marketplace Coverage
You’ll also need financial documentation to calculate your household’s modified adjusted gross income. Pull together your most recent tax return, W-2s, pay stubs, and records of any other income like self-employment earnings, Social Security benefits, or investment income. If your employer offers insurance, you’ll need the details of that plan’s cost even if you aren’t enrolled in it, so the Marketplace can run the affordability test.
Discrepancies between what you enter and what the government has on file can trigger a request for extra documentation, which delays enrollment. Having everything in front of you before you start the form makes it move much faster.
Finishing Your Enrollment
Picking a plan does not mean you have insurance. You have to pay your first month’s premium, sometimes called a binder payment, directly to the insurer by the deadline shown in your plan details. If you don’t pay, the enrollment is cancelled.16HealthCare.gov. Complete Your Enrollment and Pay Your First Premium This is where people most often stumble, finding out weeks later that coverage never activated.
Once your payment processes, the insurer mails a membership packet with your card and benefits summary. If the card hasn’t arrived in a few weeks, call the insurer to confirm your coverage is active before you need to use it.
Bridges Between Plans
If you lose employer coverage because of a job change, layoff, reduction in hours, or certain other events, COBRA lets you keep that same group plan temporarily. Federal COBRA applies to employers with 20 or more employees, and you get at least 60 days from your election notice to decide whether to opt in.17Centers for Medicare & Medicaid Services. COBRA Continuation Coverage Questions and Answers The catch is cost: you pay the full premium plus an administrative fee of up to 2%, bringing the total to 102% of the plan’s real cost.18eCFR. 26 CFR 54.4980B-8 – Paying for COBRA Continuation Coverage Losing job-based coverage also opens a Marketplace Special Enrollment Period, so COBRA is rarely your only option, and for most people a subsidized Marketplace plan ends up cheaper.
Short-term, limited-duration insurance is a different kind of bridge. Under federal rules, these plans can last no more than three months, with a maximum coverage period of four months including renewals.19Centers for Medicare & Medicaid Services. Short-Term, Limited-Duration Insurance and Independent, Noncoordinated Excepted Benefits Coverage Premiums are low, but insurers can deny you based on health history, exclude pre-existing conditions, cap annual or lifetime payouts, and skip whole benefit categories like maternity care or mental health. Short-term plans don’t count as minimum essential coverage and don’t qualify for premium tax credits. For a few weeks between jobs they can limit your exposure to a catastrophic bill. For anything longer, the Marketplace or COBRA is almost always the better call.
If You’re Denied
If the Marketplace finds you ineligible for coverage or for the subsidy you expected, you have 90 days from the date on the eligibility notice to appeal. You can file online through your HealthCare.gov account, by mail, or by fax.20Centers for Medicare & Medicaid Services. Appealing Eligibility Decisions in the Health Insurance Marketplace The Marketplace tries an informal resolution first and mails a letter with the result; if you disagree, you can request a formal hearing by phone. Appeals tend to matter most when a data mismatch caused the denial, like an income discrepancy you can clear up with current pay stubs or an employer letter.
A Note on the Mandate
The federal tax penalty for going without health insurance was reduced to $0 starting in 2019, so there is no federal fine for being uninsured.21HealthCare.gov. Exemptions From the Fee for Not Having Coverage A handful of states and the District of Columbia have their own individual mandates with state-level tax penalties, though. If you live in one of them, check your state’s tax authority before deciding to go without coverage.