ACA Marketplace 101

How Healthcare.gov actually works.

The Affordable Care Act created the health insurance Marketplace, a federally run or state-run exchange where individuals and families without employer coverage can shop for insurance. Knowing how it works saves real money, especially because many people leave subsidies on the table every year.

Who the Marketplace is for

• Self-employed people.
• Anyone whose employer doesn't offer health insurance.
• People whose employer coverage is too expensive to be "affordable" by ACA standards.
• Early retirees not yet eligible for Medicare.
• People between jobs without COBRA.

The metal tiers

All Marketplace plans fall into four categories based on how costs are split between you and the insurer:

• Bronze, about 60% covered by the insurer. Lowest premium, highest deductible. Best for healthy people who rarely see a doctor.
• Silver, about 70% covered. Moderate premium and deductible. Best if you qualify for cost-sharing reductions.
• Gold, about 80% covered. Higher premium, lower deductible. Best for frequent care users.
• Platinum, about 90% covered. Highest premium, lowest out-of-pocket.

Catastrophic plans are available for people under 30 or with hardship exemptions.

The subsidy everyone misses

Premium tax credits (APTC) reduce monthly premiums based on income. After the Inflation Reduction Act extensions through 2025, subsidies are available for households earning up to 400% of the federal poverty level, and in some cases beyond. A family of four earning $90,000 can often get $600 or more per month in subsidies without realizing it.

Cost-sharing reductions (CSRs), available only on Silver plans, reduce deductibles and out-of-pocket maximums for lower-income households. This is why Silver is often the best value when you qualify.

Enrollment windows

• Open Enrollment, November 1 to January 15 in most states (different dates in some state exchanges).
• Special Enrollment Periods, triggered by qualifying life events: marriage, divorce, birth or adoption, loss of other coverage, moving to a new state, income changes affecting subsidy eligibility.

Outside these windows, you generally can't buy Marketplace coverage.

State exchanges in OnePoint's footprint

• State-run exchanges: MD, NJ, NY, VA (transitioned to state-based for 2024). These use their own websites.
• Federal exchange (Healthcare.gov): AL, AZ, FL, GA, IL, LA, MI, MS, MO, NC, OH, SC, TN, TX.

For reading on short-term alternatives and supplemental coverage, see our posts on short-term medical, hospitalization indemnity, and critical illness. Our health insurance page covers Marketplace enrollment.

Medicare Parts A, B, C, and D

The letters explained.

Medicare is federal health insurance for people 65 and older and certain people with disabilities. It's built as four separate parts, each covering different things and sold through different channels. The letters confuse everyone.

Part A, Hospital Insurance

Covers inpatient hospital stays, skilled nursing facilities, hospice, and some home health. Most people don't pay a premium for Part A if they or their spouse paid Medicare taxes for 10 or more years (40 quarters). You still pay deductibles and coinsurance for each hospital stay.

Part B, Medical Insurance

Covers doctor visits, outpatient care, preventive services, durable medical equipment, and ambulance rides. Everyone pays a monthly Part B premium, $185 per month in 2025 for most people, higher for high earners (IRMAA surcharge).

Part B has a small annual deductible ($257 in 2025) and then covers 80% of approved costs. You pay the other 20%, and there's no cap on that 20%. This is why most people on original Medicare also buy a Medigap policy (see the next module).

Part C, Medicare Advantage

Private insurance plans that bundle Parts A and B (and usually D) into one plan. Often includes dental, vision, hearing, and gym memberships. Limits your out-of-pocket spending (which original Medicare doesn't), but usually restricts you to network providers.

Premiums can be as low as $0 per month (above the Part B premium you still pay). Trade-offs: network limits, prior authorizations for certain services, and care that can be harder to access when you travel.

Part D, Prescription Drug Coverage

Covers prescription medications. Sold separately as a standalone plan (if you have original Medicare) or bundled into a Medicare Advantage plan.

In 2025, the Inflation Reduction Act capped total out-of-pocket prescription drug spending at $2,000 per year, a major change for people on expensive medications.

The enrollment window that matters

• Initial Enrollment Period, the 7-month window around your 65th birthday (3 months before, your birthday month, 3 months after). Missing this can mean lifetime penalties on Parts B and D.
• Annual Open Enrollment, October 15 to December 7. Switch plans, add or change Part D, switch between original Medicare and Medicare Advantage.
• Medicare Advantage Open Enrollment, January 1 to March 31. One-time switch out of or between MA plans.

The big decision: Original Medicare plus Medigap, or Medicare Advantage?

Most people facing Medicare enrollment choose between:

1. Original Medicare (A plus B) plus Medigap plus Part D, freedom to see any provider who accepts Medicare, predictable costs, higher monthly premium.
2. Medicare Advantage (Part C), lower monthly premium, network restrictions, out-of-pocket cap, extra benefits.

Neither is universally better. It depends on your health, your providers, where you travel, and your budget.

Our health insurance page covers Medicare enrollment and plan comparison.

Medigap (Medicare Supplement)

Filling original Medicare's gaps.

Original Medicare covers about 80% of most medical costs. The other 20%, plus the deductibles and the coinsurance, is on you, with no cap. A Medicare Supplement (Medigap) policy fills those gaps. For people who want predictable costs in retirement, Medigap is the piece that makes the system sustainable.

How Medigap works

Medigap is sold by private insurers and is standardized by the federal government. Every "Plan G" from every insurer covers the same things, the only difference is price and service. This makes shopping simpler: find the cheapest Plan G in your area and the coverage is identical across carriers.

The standardized plan letters

Plans are labeled A, B, C, D, F, G, K, L, M, and N. The most common today:

• Plan G, the most popular plan for new enrollees. Covers everything original Medicare doesn't, except the small Part B deductible ($257 in 2025).
• Plan N, lower premium than Plan G, with small copays for doctor and ER visits ($20 to $50).
• Plan F, the most comprehensive plan, but no longer available to people who became eligible for Medicare after January 1, 2020.

Wisconsin, Massachusetts, and Minnesota have their own standardization systems, but all 18 OnePoint states use the standard federal system.

What Medigap doesn't cover

• Prescription drugs (you need a separate Part D plan).
• Dental, vision, hearing (separate plans or Medicare Advantage).
• Long-term care.

What it costs

Plan G premiums vary significantly by state, age, gender, and tobacco use:

• Age 65, non-smoker, Plan G: $120 to $200 per month in most OnePoint states.
• Age 75, non-smoker, Plan G: $180 to $300 per month.
• Age 85, non-smoker, Plan G: $250 to $400 or more per month.

Rates in FL, NJ, and NY are generally higher than in GA, TN, and SC.

The Medigap Open Enrollment window, don't miss it

For the 6 months starting the month you turn 65 and are enrolled in Part B, insurers must sell you any Medigap plan with no medical underwriting. Outside this window (in most states), insurers can ask health questions and decline you.

A few states offer more generous rules, NY and CT allow continuous guaranteed issue for Medigap, but most of OnePoint's states don't. Miss the 6-month window and you may not be able to buy Medigap later, or you'll pay substantially more.

Medigap vs. Medicare Advantage

You can have Medigap or Medicare Advantage, not both. Medigap pairs with original Medicare. Medicare Advantage replaces original Medicare with a private plan.

Our health insurance page covers Medigap alongside Medicare Advantage and Part D.

Health Savings Accounts (HSAs)

The most underused tax break in America.

A Health Savings Account is a tax-advantaged account paired with a high-deductible health plan (HDHP). It's the only account with triple tax benefits, contributions go in tax-free, grow tax-free, and come out tax-free for qualified medical expenses. For people who can afford to fund one, it's the most tax-efficient account in the American system.

Who qualifies

• Enrolled in a HDHP (minimum deductibles and out-of-pocket maximums are set annually by the IRS).
• Not enrolled in other non-HDHP health coverage (including most FSAs).
• Not enrolled in Medicare.
• Not claimed as a dependent on someone else's tax return.

2025 contribution limits

• Individual HDHP coverage: $4,300.
• Family HDHP coverage: $8,550.
• Age 55 and older catch-up: extra $1,000.

The triple tax benefit

1. Contributions reduce your taxable income (above-the-line deduction).
2. Earnings grow tax-free inside the account.
3. Withdrawals for qualified medical expenses are tax-free.

After age 65, you can withdraw for any reason, non-medical withdrawals are taxed as ordinary income (like a traditional IRA), but no penalty.

Qualified medical expenses

• Doctor visits, copays, prescriptions.
• Dental, vision, hearing, mental health.
• Medicare premiums (Parts B, D, Medicare Advantage) after age 65.
• Long-term care insurance premiums (up to IRS limits).

What isn't qualified: cosmetic procedures, most over-the-counter items (some changed during COVID), and gym memberships (usually).

The "receipt bank" strategy

You can reimburse yourself for medical expenses from your HSA years, even decades, later, as long as you have receipts. Some people pay medical expenses out of pocket for 20 years, let the HSA grow invested, and then reimburse themselves tax-free in retirement.

Investing the balance

Most HSAs allow you to invest the balance above a small cash minimum ($1,000 to $2,000). Over 20 or more years, an invested HSA can grow to six figures, tax-free.

HSA vs. FSA

HSA rolls over year to year. FSA doesn't (use-it-or-lose-it, with small carryover allowances). HSAs are portable across jobs; FSAs aren't.

Our health insurance page covers HDHPs and HSA-qualified plans.

FSA vs. HSA

The tax accounts that look identical and aren't.

Flexible Spending Accounts and Health Savings Accounts both let you pay for medical expenses with pre-tax dollars. They sound interchangeable. They're not. Picking the wrong one, or not using the one you have, leaves real money on the table.

FSA basics

• Offered through employers. You can't open one on your own.
• Available with any health plan (PPO, HMO, HDHP).
• 2025 limit: $3,300 per employee (plus separate dependent care FSA at $5,000).
• Use-it-or-lose-it. Unused funds generally don't roll over, though employers may allow up to $660 carryover or a grace period through March 15.
• Funded upfront. Your full annual election is available on day one of the plan year.
• Not portable. Leave the employer, lose any remaining balance.

HSA basics

• Available only with HDHPs.
• You own the account. Portable across jobs, banks, and retirement.
• 2025 limit: $4,300 individual or $8,550 family.
• Rolls over forever.
• Can be invested.
• Funded as you contribute.

When each one wins

• FSA is better when: your employer doesn't offer an HDHP, you know you'll spend your contribution in the plan year, or you want access to the full annual amount on January 1.
• HSA is better when: you have access to an HDHP, you can afford to build up a balance for future medical costs or retirement, and you want long-term growth.

Dependent Care FSA is separate

The Dependent Care FSA covers childcare, before and after school programs, and elderly dependent care. Separate from the medical FSA with its own $5,000 limit. Usable with either a healthcare FSA or HSA.

Limited-Purpose FSA

If you're enrolled in an HDHP with an HSA, you can still have a Limited-Purpose FSA restricted to dental and vision expenses only. Useful for predictable orthodontia or LASIK costs.

Common mistakes

• Treating FSA elections as "set it and forget it" and losing unused funds.
• Not reimbursing yourself from an HSA for eligible expenses.
• Double-dipping, submitting the same expense to both an FSA and HSA.
• Assuming an FSA covers what an HSA does. HSAs have slightly broader eligibility in retirement.

Our health insurance page covers FSA and HSA-qualified plan options.

Dental Insurance

What it actually covers, and doesn't.

Dental insurance is unusual in the insurance world, it's priced more like a prepaid discount plan than true catastrophic coverage. Understanding that framing saves you from being surprised by its limits.

How a typical plan works

• Preventive care (cleanings, X-rays, exams): 100% covered, usually twice a year.
• Basic care (fillings, simple extractions, root canals): 70 to 80% covered.
• Major care (crowns, bridges, dentures, implants): 40 to 50% covered.
• Orthodontics: often a separate rider with lifetime limits.

The annual maximum

Most dental plans cap payouts at $1,000 to $2,500 per year. That limit hasn't meaningfully changed in 30 years, in 1990, a $1,000 annual max was generous. Today, a single crown can cost $1,500.

The waiting period

Most plans have waiting periods for major services, typically 6 to 12 months before crowns and root canals are covered. Plans with no waiting period exist but usually cost more.

PPO vs. DHMO

• PPO (Preferred Provider Organization): see any dentist, pay less in-network. Higher premium, more flexibility.
• DHMO (Dental HMO): must use network dentists, no annual max, very low cost. Best if good in-network providers are nearby.

What it costs

• Individual PPO: $25 to $50 per month.
• Family PPO: $65 to $120 per month.
• Individual DHMO: $10 to $25 per month.

Dental discount plans (not insurance)

Some companies sell "dental discount plans", not insurance, but membership programs that negotiate 15 to 50% off at participating dentists. Lower cost, no annual max, no waiting periods. Pay full price at the dentist, get the discount at checkout.

Medicare and dental

Original Medicare doesn't cover routine dental. Medicare Advantage plans often include dental, but with significant limits. Standalone dental insurance is common for retirees.

Our health insurance page covers dental alongside medical and vision.

Vision Insurance

Usually not worth the math.

Vision insurance is one of the few insurance products where it's worth running the math yourself before buying. For many people, paying out of pocket is cheaper than the premium.

How vision plans work

Typical annual benefits:

• Eye exam: covered in full or with a small copay ($10 to $25).
• Frames: $130 to $200 allowance once every 1 to 2 years.
• Lenses: basic lenses covered; extras (anti-glare, photochromic, progressives) cost extra.
• Contact lenses: allowance instead of glasses, usually $120 to $200.

What it costs

• Individual plan: $10 to $20 per month.
• Family plan: $25 to $45 per month.

The math most people miss

A $15 per month plan costs $180 per year. You get one exam ($120 out of pocket), frames up to $150, and a lens allowance. If you only need an exam, out-of-pocket is cheaper. If you wear glasses and need new frames every two years, a plan may break even.

When it's actually worth it

• You wear prescription glasses and update them regularly.
• Multiple family members need glasses.
• You have kids needing kid-specific plans (with frame breakage coverage).
• You wear contacts and buy them by prescription.
• Your employer pays most or all of the premium.

When it's not worth it

• You don't wear glasses or contacts.
• You wear glasses but keep the same frames for years.
• You're comfortable paying $250 to $400 out of pocket every 1 to 2 years.

Medical vs. vision insurance

Your regular health insurance covers eye problems that are medical conditions, glaucoma, cataracts, retinal detachment, diabetic eye disease. Vision insurance covers routine exams and eyewear. If you have a medical eye issue, it goes through your health plan, not your vision plan.

LASIK and vision insurance

Vision plans sometimes offer LASIK discounts (typically 15 to 25% off) but rarely cover the procedure. Average cost after discounts: $2,000 to $3,000 per eye.

Our health insurance page covers vision alongside medical and dental.

COBRA

What it is, what it costs, and when it's worth it.

When you lose your job, get divorced, or age off a parent's plan, COBRA gives you the right to keep your old health insurance for a while, at a cost. It's a critical bridge for some people. For others, it's far more expensive than it needs to be.

What COBRA is

The Consolidated Omnibus Budget Reconciliation Act (1985) requires employers with 20 or more employees to offer departing workers the option to continue their group health plan for a set period, usually 18 months, up to 36 in certain family situations.

Qualifying events:

• Loss of job (voluntary or involuntary, except for gross misconduct).
• Reduction in hours that ends group coverage.
• Divorce or legal separation (spouse).
• Death of covered employee (dependents).
• Aging off parent's plan at 26 (dependents).
• Employee's Medicare entitlement (dependents).

The cost problem

When employed, your employer pays most of your health insurance premium. Under COBRA, you pay the full premium plus a 2% administrative fee. A plan that cost you $150 per month while employed might cost $850 per month under COBRA, because that's what the full plan actually costs.

Typical COBRA costs:

• Individual: $550 to $900 per month.
• Family: $1,800 to $2,800 per month.

When COBRA makes sense

• You have ongoing specialists or treatments you can't easily transition.
• You're in the middle of a deductible year and don't want to reset it.
• You need short-term coverage (3 to 6 months) while between jobs.
• You have specific prescriptions tied to your plan's formulary.

When it doesn't

• You qualify for Marketplace subsidies that make ACA coverage far cheaper.
• You're about to turn 65 and can enroll in Medicare.
• You can join a spouse's plan (marriage or job change triggers special enrollment).

The ACA alternative

Loss of job-based coverage triggers a Special Enrollment Period on the Marketplace. Many people who would have been stuck with COBRA now qualify for premium subsidies that cut their cost by 50 to 80%. Always compare COBRA cost against a Marketplace plan before electing.

The 60-day window

You have 60 days from your qualifying event (or notice date, whichever is later) to elect COBRA. If you elect, coverage is retroactive to the date you lost coverage, meaning you can wait and see if you need it. If you don't have medical needs during the 60 days, you can decline and choose a cheaper option.

State continuation ("mini-COBRA")

Employers with fewer than 20 employees aren't subject to federal COBRA, but many OnePoint states have state continuation laws:

• NY requires continuation up to 36 months.
• IL, NJ, TX, VA, GA, SC, and others have varying continuation periods (usually 3 to 18 months).
• TN, MO, and LA have weaker state continuation rules.

Our health insurance page covers COBRA alongside Marketplace and short-term options, and our short-term medical post covers bridge coverage alternatives.