Jesse Smedley is the Principal Broker for iHealthBrokers and the founder, president, and CEO of Smedley Insurance Group, Inc. and iHealthBrokers.com. Since the inception of SIG in 2007, Jesse has been dedicated to helping people save money on their health insurance by providing them with resources to educate themselves on all their health insurance options, both under age 65 and Medicare beneficiaries. He is featured in many publications as well as writes regularly for expert columns regarding health insurance and Medicare.
When selecting a health insurance plan, it is vital that you understand basic terminology, ACA rules, 2026 changes and cost-saving strategies. A simple misstep can cost you time, energy and a lot of money.
ACA Basics & Key Terminology
The ACA is also known as the Affordable Care Act, Marketplace plans, or Obamacare. ACA plans are designed for people with no employer coverage who don’t qualify for Medicaid. They are intended for people for whom private insurance is unaffordable or untenable.
However, marketplace language can be overwhelming. So, understanding terms will lead to better plan decisions!
Understanding ACA Costs
There are many costs associated with marketplace plans and health insurance in general.
Monthly Premium
First, there is your monthly premium. This is the fee paid monthly to keep coverage active.
You may be eligible for a premium tax credit also known as a premium subsidy. This is simply a tax credit that is paid upfront to lower monthly premiums. Under the American Rescue Plan Act and the Inflation Reduction Act, PTC were enhanced and expanded. But, these are scheduled to expire at the end of 2025. If that happens, premium may increase up to 75% for some households
Deductible
The deductible is the amount paid before insurance begins cost sharing. Many ACA services covered before deductible like preventive care. Often these services have no copay or coinsurance.
There can be individual vs family deductibles if you are enrolled on a family plan. Even if you have not met your individual deductible, if the combined expenses of your family have me the family deductible, it is considered meeting the deductible for everyone covered. This is designed to help save you money.
Cost Sharing
Once you have met your deductible, your insurance will begin to contribute to the cost share. Your contribution will either be a copay or a coinsurance.
A copay is a fixed amount i.e., $25 for PCP, $50 for Urgent Care, $500 for ER, etc…
Coinsurance is a variable amount. You will pay a percentage of the cost i.e. 20%, 50%, etc…
Out-of-Pocket Maximum (MOOP)
If you continue to spend, you may reach your our of pocket maximum. This is the maximum annual amount you may have to spend for covered in-network services. Once met, your insurance pays 100% of the covered costs for the rest of the plan year.
The maximum out of pocket maximum is set federally, but plans may offer lower limits.
Major 2026 Marketplace Changes
Financial Changes
In 2026, beneficiaries will have to contend with the likely expiration of enhanced premium tax credits. Therefore, you may need to budget differently to accommodate higher premiums or even explore alternatives if ACA plans become unaffordable.
Regulatory & Eligibility Changes
In 2026, there have also been changes to gender-affirming care and Dreamer eligibility. But some proposed changes have been halted by a federal court, for example, special enrollment restrictions, additional paperwork, and monthly junk fees. Currently, these additional policies are in limbo.
ACA Metal Tiers Explained
Often, ACA plans are divided into metal tiers. These tiers reflect the cost sharing structure, not the quality.
- Bronze: 60% insurer / 40% member
- Silver: 70% insurer / 30% member
- Gold: 80% insurer/ 20% member
- Platinum: 90% insurer/ 10% member
You will likely notice that plans with higher deductibles or coinsurance (Bronze and Silver) will have lower monthly premiums and plans with lower out of pocket costs (Gold and Platinum) will have higher monthly premiums.
Bronze Plans
Bronze plans will offer lower monthly premiums but usually higher deductibles and cost sharing. These types of plans are best for those with minimal medical use or even emergency-only coverage.
Silver Plans
Silver plans offer the potential for Cost-Sharing Reductions (CSR). Eligibility is based on income and household size. If you are eligible for CSR, you will see lower deductibles, copays, and coinsurance. This can make these plans even more cost effective than a Platinum plan.
Gold & Platinum Plans
Gold and Platinum plans will have higher monthly premiums, but lower deductibles and out-of-pocket costs. They are better for people who need more frequent care or those with chronic conditions.
High-Deductible Health Plans (HDHPs) & HSAs
HSAs are Health Savings Accounts. Traditionally, they have only been available with qualifying HDHPs, but in 2026, they will be available with all Bronze and Catastrophic plans as well.
HSAs offer the triple tax advantage. Contributions are pre-tax, and they lower your taxable income and MAGI. This can increase your premium tax credit eligibility. Accounts are interest bearing, and interest accrued is tax free. You can also invest a portion of your HSA, and the investment growth is tax-free.
The funds roll over year to year, and if you hold onto them until age 65, they can be used as a retirement account.
The 10 Essential Health Benefits
All ACA plans must offer the 10 essential benefits. This is a major tenet of the ACA. Plans must offer:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health & substance use services
- Prescription drugs
- Rehabilitative & habilitative services
- Laboratory services
- Preventive & wellness care
- Pediatric services (including vision & dental)
Additionally, there is no medical underwriting, and pre-existing conditions are fully covered.
Navigating Healthcare.gov
You can preview and compare plans on healthcare.gov or your state’s individual marketplace. You will be asked a series of questions to determine your PTC eligibility.
When comparing plans, you can sort by lowest monthly premium or lowest deductible. You can also filter by monthly premium, metal tier, plan type, insurance carrier, HSA eligibility, and more.
This allows you to compare plans more easily. You can click on three plans to view side by side.
You must pay close attention to drug tiers and copays/coinsurances for your basic medical care.
If you are interested in a specific plan, make sure to review the Summary of Benefits, Plan brochures, Provider directories, and Drug formularies. Don’t choose based on premium alone!
