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.
Choosing a health insurance plan is always confusing! 2026 promises to be more stressful than ever with sweeping marketplace changes. So, how do you pick the best possible plan in 2026?
2026 Changes
In 2026, Marketplace plans are changing significantly. According to the Kaiser Family Foundation, insurers are requesting a median premium increase of approximately 18% for 2026 Marketplace plans. But you will likely see a much more significant increase, largely due to the expiration of enhanced premium tax credits.
One of the most impactful changes is the expiration of the expanded premium tax credits under the American Rescue Plan Act and the Inflation Reduction Act. Unfortunately, these are set to expire at the end of 2025. If Congress does not act, many Americans could see premiums rise by as much as 75% (and these are not the only increasing costs).
For 2026, the maximum out-of-pocket limit for individuals will be $10,600 and $21,200 for families. These higher thresholds could mean much bigger bills for those with significant medical expenses.
Out of Pocket Costs
Your monthly premium is the easiest cost to understand. It is the amount you pay monthly to keep your insurance active. It is only one part of a plan’s overall cost structure (and it’s likely on the rise!)
Your plan will also have a deductible. The deductible is the amount a member must pay out of pocket before the insurance company begins contributing to cost-sharing. Some services, such as primary care visits or urgent care, may be covered prior to meeting the deductible.
Once you have met your deductible, you will be responsible for a copay or coinsurance. Copays are fixed dollar amounts (e.g., $25 for a specialist visit), while coinsurance is a percentage of the cost (e.g., 20% or 40% of a facility charge). Coinsurance amounts vary greatly and can cause expenses to escalate quickly, especially for high-cost services.
If you continue to spend, you may reach the out-of-pocket maximum. The out-of-pocket maximum is the most you will pay in a year for covered in-network services. Once met, the plan covers eligible services at 100% for the remainder of the year. Out-of-network or excluded services do not count toward this limit.
Questions to Ask Yourself Before Choosing a Plan
In order to pick the best possible plan for your needs, you should ask yourself several questions.
How Often Do You Use Healthcare Services?
People with frequent medical needs or chronic conditions may benefit from plans with higher monthly premiums but lower deductibles and lower out-of-pocket costs during the year.
Do You Prefer Lower Monthly Costs or Predictable Costs?
Healthier individuals who rarely seek medical care may find lower-premium, higher-deductible plans cost-effective. Meanwhile, people with ongoing care needs should consider plans with higher premiums but lower cost-sharing.
Which Metal Tier Aligns With Your Needs?
One of the more confusing aspects of marketplace plans is the metal tiers. The metal tier is not indicative of the plan’s quality; it simply signifies the cost-sharing structure.
- Bronze: 60/40 cost split; suitable for low medical usage and lower monthly premiums.
- Silver: 70/30 cost split; preferred for those who qualify for cost-sharing reductions.
- Gold: 80/20 cost split; typically better for higher medical utilization.
- Platinum: 90/10 cost split; best for those who expect substantial care but include the highest premiums.
Are You Eligible for Extra Savings?
Cost-sharing reductions (CSR) are only available on Silver plans. For qualifying enrollees, Silver plans may offer lower out-of-pocket costs than even Gold or Platinum plans!
Networks
Marketplace plans operate on networks. There are HMOs, PPOs, and EPOs.
HMO Plans
HMO plans generally offer lower premiums but require a primary care physician and referrals for specialists. They provide no out-of-network benefits except in emergencies.
PPO Plans
PPO plans offer the most flexibility. They allow members to see both in-network and out-of-network providers without referrals, though out-of-network services cost more. These plans typically have higher premiums.
EPO Plans
EPOs combine features of HMOs and PPOs. They do not require referrals, but they do not cover out-of-network care. Their premiums generally fall between HMO and PPO plan pricing. Remember that, regardless of plan type, you can receive covered out of network care in the case of a true medical emergency.
