AFFORDABLE CARE ACT (ACA/OBAMACARE)

Some eligible applicants may find Marketplace plans with a $0 monthly premium after a premium tax credit is applied. A $0 premium does not mean all heath care is free; deductibles, copayments, coinsurance, and costs for non-covered or out-of-network services may still apply.

Eligibility for Marketplace coverage and financial assistance depends on several factors, including residency, citizenship or lawful presence, household income, household size, and access to other qualifying coverage. MBhealth can help you review your eligibility and compare available plans.

Before selecting a Marketplace plan, it is important to understand the network types available in your area. Common types include:

• Health Maintenance Organization (HMO): Generally, limits coverage to in-network care except in an emergency. Some HMOs may require referrals for specialist care.
• Exclusive Provider Organization (EPO): Generally, covers services only when you use in-network providers, except in an emergency
• Preferred Provider Organization (PPO): Generally, allows both in-network and out-of-network care, although out-of-network care usually costs more. Referrals typically are not required.

Plan types and network rules vary. Review the plan documents and provider directory before enrolling. MBhealth can help you compare the options available in your area. Call us for help.

An offer of job-based coverage may affect eligibility for Marketplace premium tax credits. For 2026, employee-only coverage is generally considered affordable if the employee’s required contribution for the lowest-cost plan that meets minimum-value standards is no more than 9.96% of household income. For family members, affordability is evaluated using the employee’s cost to cover the household members included in the employer’s offer.

The affordability percentage is adjusted annually. MBhealth can help you review how an employer’s offer may affect your household’s Marketplace savings.

Looking at coverage options, premium tax credits are generally available to eligible households with income between 100% and 400% of the federal poverty level. Other rules also apply, including rules involving access to affordable employer-sponsored coverage, Medicare, Medicaid, and tax filing status. Income limits change based on household size and are updated annually.

Marketplace savings are based on your expected household income for the year the coverage is effective. If your income or household changes, update your Marketplace application. Any advance premium tax credit is reconciled when you file your federal tax return, which may affect your refund or the amount you owe.

An out-of-pocket maximum is the most you pay during a plan year for covered, in-network services before the plan begins paying 100% of covered in-network benefits. Amounts you pay toward the deductible, copayments, and coinsurance generally count toward this limit.

Monthly premiums, non-covered services, and amounts above a plan’s allowed charge generally do not count. Out-of-network costs may not count, depending on the plan. Review the plan’s Summary of Benefits and Coverage for details.

For 2026, a Marketplace plan’s out-of-pocket limit cannot exceed $10,600 for an individual or $21,200 for a family, although many plans have lower limits. These amounts can change each year.

The Affordable Care Act enacted in 2010 had two main purposes. One was to enable more Americans to obtain health insurance.

This main feature eliminated the problems for individuals with pre-existing medical conditions. Since most health insurance companies would not cover costs for pre-existing conditions, many people were locked into jobs that provided them with insurance. The ACA removed the worry for people with pre-existing conditions so these individuals can now make life changes and maintain insurance coverage.

Secondly, it takes into consideration each individual or family’s income situation. By doing so it allows premiums to be reduced to a more affordable level. Your income also can adjust your deductibles and out-of-pocket limits.

To get the best out of the ACA for yourself and your family, let MBhealth advise you on your specific situations.

Yes, anyone who has obtained health insurance from the Marketplace can make changes, renew or cancel policies during Open Enrollment periods. Open Enrollment starts November 1 and ends December 15. This is when you can renew your current plan if it still meets your needs, or change to a new one.

During this period, you should create a new estimate of your income for the upcoming year. This figure will help determine whether you can receive a subsidy (premium tax credit) or benefit reduction on your health insurance.

If you take no action by December 15, you may automatically be re-enrolled in the same plan (if it continues to be available) with an effective date of January 1. However, a subsidy from the federal government will be based on your prior year’s income. It could benefit you to revisit this each year.

There are situations that enable you to enroll in plans other times throughout the year. For example, if you lose your employer health insurance because of a change in employment, you get married, divorced, or have a baby. To avoid losing any benefits due to you, let MBhealth guide your health insurance decisions!

Marketplace plans cannot deny you coverage, charge you more, or refuse to cover essential health benefits because of a pre-existing condition, such as asthma, cancer, or diabetes. Once you are enrolled, the plan cannot deny coverage or raise your rate based only on your health.

Pregnancy is also covered beginning on the plan’s effective date. Covered services remain subject to the plan’s network rules, cost sharing, medical management requirements, and other terms.

To enroll in Marketplace coverage, you generally must live in the United States, be a U.S. citizen or national or be lawfully present and not be incarcerated. If you have Medicare coverage, you cannot enroll in a Marketplace health or dental plan.

Eligibility for premium tax credits and other savings has additional requirements. For example, people who are eligible for Medicaid generally are not eligible for Marketplace financial assistance. MBhealth can help you review the rules that apply to your situation.