Overview
Major medical health insurance policies can be purchased on your own rather than accessing coverage through an employer. These plans are available through the ACA Marketplace (Healthcare.gov or your state’s exchange) and directly from an insurance company, broker, or agent.
Plans purchased through the Marketplace (also referred to as an “exchange”) may be eligible for premium tax credits and/or cost-sharing reductions. Eligibility depends on a range of factors, including but not limited to household income. Plans purchased directly from an insurer are sometimes called “off-exchange” plans; they follow the same coverage rules but are not eligible for those financial subsidies. Off-exchange plans from the same insurer may have different networks or formularies even when the plan name looks identical.
All Major Medical Plans are ACA Plans
All major medical plans (also known as comprehensive health plans) sold in the United States must be ACA-compliant. This means there is no separate category of “non-ACA major medical” insurance available to consumers.
Every major medical plan must:
- cover essential health benefits
- accept applicants regardless of pre-existing conditions
- follow the ACA’s rules on cost sharing and consumer protections
A small number of people still hold “grandfathered” plans that were purchased before the ACA and exempted from some of its requirements. However, these plans cannot accept new enrollees and are steadily shrinking.
For all practical purposes, if you are shopping for major medical coverage today, you are shopping for an ACA-compliant plan. Short-term insurance, health care sharing ministries, and fixed indemnity plans are not major medical insurance and do not meet ACA standards. You can learn more about those alternative options here.
If your employer offers an Individual Coverage Health Reimbursement Arrangement (ICHRA) to help fund the purchase of an individual plan, the coverage you may buy still follows all the rules of an ACA-compliant plan. You can learn how ICHRAs work, how they affect subsidy eligibility, and how to evaluate whether the ICHRA or Marketplace premium tax credits are the better option here.
Eligibility
Some eligibility rules are the same whether you buy through the Marketplace or directly from an insurer:
- you must be a U.S. citizen or lawfully present immigrant
- you cannot be incarcerated
- you cannot be enrolled in Medicare
However, there are additional eligibility criteria for Marketplace plans. Eligibility determinations are made by the Marketplace based on your specific situation. You generally cannot enroll if you have access to qualifying, affordable employer-sponsored coverage.
"Affordable" Depends on Household Income
You generally cannot enroll through the Marketplace if you have access to qualifying, affordable employer-sponsored coverage. Under current rules, “affordable” means the employee-paid share of the premium for the lowest-cost plan offered by the employer is less than the household income threshold set by the IRS for the plan year. For the 2026 plan year, the threshold is 9.96% of household income. The household income threshold may be subject to change every year.
If your employer’s plan exceeds the threshold, you may be eligible for Marketplace subsidies instead. Other household members may qualify for subsidized Marketplace plans when an employer covers the employee affordably but charges an unaffordable rate for dependents. When employer coverage is unaffordable — meaning the employee's share of the premium for the lowest-cost self-only plan exceeds the household income threshold for the plan year — you may qualify for subsidized coverage through the ACA Marketplace even if your employer technically offers insurance.
Losing employer coverage qualifies you for a special enrollment period, including situations where COBRA expires or is not affordable. You are not required to exhaust COBRA before enrolling in a Marketplace plan, and a subsidized Marketplace plan may be less expensive than COBRA continuation coverage for some individuals, depending on eligibility and subsidies.
If your employer offers an Individual Coverage Health Reimbursement Arrangement (ICHRA) instead of traditional group insurance, your eligibility for premium tax credits depends on whether the ICHRA is considered affordable. You can find a full explanation of how ICHRAs work and how to determine which option is the better value here.
Subsidies
In the Marketplace, premium tax credits are available on a sliding scale relative to the federal poverty level. Cost-sharing reductions, which lower deductibles, copays, and out-of-pocket maximums, apply only to Silver-tier plans and are available to households earning between 100% and 250% of the federal poverty level. Cost-sharing reduction benefit levels vary within the 100%–250% federal poverty level range and tend to be the most valuable at lower income levels. Even with cost-sharing reductions, Silver plans might not be the lowest cost option available. Other subsidies may exist on state-based exchanges.
Enrollment
Major medical plans follow the same Open Enrollment schedule and Special Enrollment Period rules regardless of whether you purchase through the Marketplace or directly from an insurer. For Marketplace plans, you enroll through Healthcare.gov or your state’s exchange. For plans purchased directly, you apply through the insurance company’s website, a licensed broker, or an agent.
Starting in the Fall of 2026, Open Enrollment will end on December 15 in many states. Plans selected during Open Enrollment will take effect on January 1, with no option for a later start date without a special enrollment period. State-run exchanges will have the option to extend their enrollment period later than December 15, but not later than December 31. Outside of the Open Enrollment window, you may only sign up for a major medical plan during a Special Enrollment Period triggered by a qualifying event.
Special Enrollment Period
Several life events open a 60-day Special Enrollment Period during which you can enroll in or change a Marketplace plan outside of Open Enrollment.
When applying during a Special Enrollment Period, you must attest to and, in some cases, provide documentation for qualifying events. Documentation may include proof such as a termination letter, marriage certificate, lease in a new coverage area, or another form of documentation, depending on the qualifying event. Misrepresentation may result in loss of coverage or financial penalties.
Qualifying events include:
- losing job-based insurance
- aging off a parent’s plan at 26
- the end of a COBRA continuation period
- losing Medicaid or CHIP eligibility
- marriage
- the birth or adoption of a child
- divorce
- permanent move to a new coverage area
- a significant change in household that causes you to gain or lose eligibility for premium tax credits or Medicaid
- being a victim of domestic abuse or spousal abandonment who loses access to a spouse’s coverage
- gaining U.S. citizenship or lawful immigration status
If a Marketplace or insurer error prevented you from enrolling or caused an incorrect enrollment, you may qualify for a correction-based Special Enrollment Period.
Approval
All major medical plans guarantee approval when enrolling during Open Enrollment or a valid Special Enrollment Period. There is no medical underwriting, no health questionnaire, and no pre-existing condition exclusion. For plans purchased through the Marketplace, income and household information is generally verified electronically against previous tax records. Applicants may be asked to submit supporting documentation.
Subtypes / Plan Variations
Both Marketplace and off-exchange plans use the same Bronze, Silver, Gold, and Platinum tiers and actuarial value standards. However, plan designs, provider networks, and prescription drug formularies may differ between the Marketplace version and the off-exchange version of a plan, even when offered by the same insurer. It is worth comparing both options before making a decision, paying particular attention to whether you qualify for subsidies through the Marketplace.
Bronze plans
- carry the lowest premiums and the highest out-of-pocket costs
- cover about 60% of healthcare expenses on average
- best suited for people who rarely use medical care and want affordable monthly payments with protection against catastrophic costs
Silver plans
- offer moderate premiums and moderate cost-sharing
- cover about 70% of expenses on average
- silver is the only tier eligible for cost-sharing reductions on the Marketplace. Cost-sharing reductions can dramatically lower deductibles and out-of-pocket maximums for households earning between 100% and 250% of the federal poverty level
- silver plans are often the best value on the Marketplace
Gold plans
- have higher premiums but lower costs when you actually use care
- cover about 80% of expenses on average
- a good fit for people who visit doctors frequently or take ongoing medications and want more predictable out-of-pocket spending
Platinum plans
- carry the highest premiums and the lowest out-of-pocket costs
- covering about 90% of expenses on average
- not available in every market
Catastrophic plans
- only available to individuals under 30 or those who have received a hardship or affordability exemption
- very low premiums and a very high deductible
- over three primary care visits per year and preventive services at no cost before the deductible applies
- not eligible for premium tax credits.