Know the Basics: ACA Health Plans (Individual & Family Coverage)
If you’re self-employed, between jobs, losing employer coverage, or simply shopping for a better option, ACA (Affordable Care Act) plans can provide comprehensive health coverage—often with financial help available based on household size and income.
Individual Health
What are ACA plans?
ACA plans (also called Marketplace or Exchange plans) are individual and family health insurance policies that follow Affordable Care Act rules. They’re designed to offer meaningful coverage with important consumer protections—like covering pre-existing conditions and including a standard set of essential benefits.
Quick takeaways
ACA plans are for individuals and families (not Medicare).
Plans are sold through the official Marketplace (in New Jersey: GetCoveredNJ).
Many people qualify for financial assistance to lower monthly premiums and/or out-of-pocket costs (based on household and income).
Who typically uses ACA plans?
Self-employed / 1099 workers
Early retirees (not yet Medicare-eligible)
People losing job-based coverage
Families needing coverage for spouses or children
Anyone who wants an alternative to employer coverage (if available)
How are ACA plans different from “private” plans you see online?
Not all health plans are created equal. ACA-compliant plans are built around standardized consumer protections and comprehensive coverage rules.
ACA plans generally include
Coverage for 10 essential health benefit categories (like doctor visits, hospital care, prescriptions, maternity, and mental health).
Preventive care covered at no cost when you use in-network providers (for many recommended services).
Clear plan levels (Bronze/Silver/Gold/Platinum) that help you compare how costs are shared.
Why this matters
Some non-ACA plans (often marketed as “short-term” or “limited benefit”) can look cheaper upfront but may leave big gaps—like limited drug coverage, benefit caps, or higher exposure when you actually need care.
Who can enroll in ACA coverage?
Most people can enroll if they live in the service area and meet Marketplace requirements. Financial help (subsidies) has additional rules.
Premium Tax Credit (monthly premium assistance) basics
Premium Tax Credit (monthly premium assistance) basics
You may qualify for the Premium Tax Credit if you enroll through the Marketplace and meet requirements—like not being eligible for affordable employer coverage or government coverage (Medicare/Medicaid/TRICARE), and meeting income guidelines.
Income guidelines (important for planning)
Under standard ACA rules, Premium Tax Credit eligibility is generally tied to household income as a percent of the federal poverty level—commonly 100% to 400% FPL (with specific exceptions).
2026 note about subsidies
The expanded/enhanced premium tax credit rules that applied for 2021–2025 sunset January 1, 2026, which can change who qualifies and how much help is available for 2026 plans.
When and how do I enroll?
In New Jersey, Open Enrollment runs from November 1 to January 31. Outside that window, you generally need a qualifying life event to enroll.
Special Enrollment Period (SEP)
If you have a qualifying life event, you can often enroll outside Open Enrollment—typically within 60 days after the event.
Common qualifying events include:
Losing health coverage (job-based, individual, student plan)
Marriage, divorce, or other household changes
Having a baby, pregnancy, adoption/foster placement (some allow earlier effective dates)
Moving to a new coverage area
Income changes that affect eligibility
Good to know
NJ FamilyCare (Medicaid) may be available year-round for those who qualify.
What do ACA plans cost—and what savings are available?
Your total cost is usually a mix of:
Monthly premium (what you pay every month)
Deductible (what you pay before the plan pays for many services)
Copays/coinsurance (what you pay when you use care)
Out-of-pocket maximum (a yearly cap on many in-network costs)
Metal levels (how costs are shared)
Marketplace plans are grouped into categories that estimate how costs are split between you and the plan:
Bronze (plan pays ~60% / you pay ~40%) – typically lower premiums, higher deductibles
Silver (~70% / ~30%) – often the “sweet spot” for many shoppers
Gold (~80% / ~20%) – higher premiums, lower cost when you use care
Platinum (~90% / ~10%) – highest premiums, lowest cost when you use care
Extra savings on Silver (Cost-Sharing Reductions)
If you qualify for cost-sharing reductions, you must choose a Silver plan to get the extra help (lower deductibles, lower copays/coinsurance, and lower out-of-pocket maximums).
Catastrophic plans
Catastrophic plans may be available for people under 30 or those with a hardship/affordability exemption.
Plan types & provider networks (this is where people get tripped up)
Even within the same metal tier, plans can work very differently depending on the network.
Common Marketplace plan types include:
EPO: Coverage generally only in-network (except emergencies)
HMO: Usually in-network only (except emergencies); may require service area rules
POS: Lower costs in-network; often requires referrals for specialists
PPO: More flexibility to go out-of-network, usually at a higher cost
Before you pick a plan, check:
Are your doctors and preferred hospitals in-network?
Are your prescriptions covered, and at what tier/cost?
Do you need referrals for specialists?
What do ACA plans cover?
All Marketplace plans cover the same core categories known as essential health benefits, including things like outpatient care, emergency services, hospitalization, prescriptions, maternity/newborn care, mental health/substance use services, lab services, preventive care, and more.
Preventive care
Many preventive services are covered at no cost to you when you use in-network providers.
Important reminder
Coverage details (copays, deductibles, covered drug lists, prior authorizations) can vary by plan—even within the same metal tier. Always review the plan’s Summary of Benefits and Coverage (SBC).
New Jersey notes: coverage requirement + staying eligible for savings
NJ health coverage requirement
New Jersey has a state health coverage requirement. If you don’t have qualifying coverage (or an exemption), you may owe a payment when you file your NJ tax return.
Premium tax credit = tax-time reconciliation
If you use advance premium tax credits to lower your monthly premium, the final amount is reconciled when you file your federal taxes—so keeping your income and household info updated is important. The IRS also notes that excess advance credits may need to be repaid depending on income and circumstances.
Catastrophic plans
Catastrophic plans may be available for people under 30 or those with a hardship/affordability exemption.
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