A plain-English guide to how health insurance works, what your coverage options are, and how to find the right plan for your budget — from a local independent advisor.
Get an Instant Quote Call (888) 564-2326| How It Works | On vs. Off-Exchange | Subsidies & Tax Credits |
| Metal Plan Tiers | Plan Types | Other Options |
| When to Enroll | FAQ | Get an Instant Quote → |
Health insurance is a contract between you and an insurance company. You pay a monthly premium to keep coverage active, and in return, the insurer helps pay for covered medical expenses — but how much they pay, and when, depends on a few key terms everyone should understand. This guide is part of NISONA's Florida Health Insurance resource center — for instant quotes and coverage options, visit our main health insurance page.
| Term | What It Means |
| Premium | Your monthly payment to keep your health insurance active — whether or not you use any medical services. Premiums vary based on your age, location, plan tier, and subsidy eligibility. |
| Deductible | The amount you pay out-of-pocket each year before your insurance starts sharing costs. With a $2,000 deductible, you pay the first $2,000 in medical bills — then your insurer starts covering a share. |
| Copay | A fixed amount you pay for a specific service — like $30 for a doctor visit or $15 for a prescription. Some plans have copays; others require you to meet your deductible first. |
| Coinsurance | After your deductible is met, you and your insurer split costs by a set percentage. With 80/20 coinsurance, your insurer pays 80% and you pay 20% of covered expenses — until you hit your out-of-pocket maximum. |
| Out-of-Pocket Maximum | The most you'll ever pay for covered services in a plan year. Once you hit this limit, your insurer covers 100% of covered costs for the rest of the year. For 2026, ACA plans cap this at $9,200 (individual) or $18,400 (family). |
| Network | The group of doctors, hospitals, and providers your plan has contracts with. Staying in-network means lower costs. Going out-of-network often means higher costs or no coverage at all, depending on your plan type. |
This is one of the most misunderstood areas of health insurance — and one of the most important. Where you buy your plan determines whether you can access federal subsidies that could save you hundreds of dollars per month.
The ACA Health Insurance Marketplace (sometimes called "the exchange" or "Obamacare") is a government platform where you shop for plans that meet Affordable Care Act standards. In Florida, the federal Marketplace is at HealthCare.gov. Plans sold here are called "on-exchange" plans.
| On-Exchange (Marketplace) | Off-Exchange (Direct) | |
| Where you buy | HealthCare.gov or a licensed broker | Directly from insurer or through a broker |
| Premium tax credits | ✓ Available if income-eligible | ✗ Not available |
| Cost-sharing reductions | ✓ Available on Silver plans | ✗ Not available |
| Best for | Anyone who may qualify for subsidies | Higher earners who don't qualify for subsidies |
Premium tax credits are federal subsidies that reduce your monthly health insurance premium. Here's what you need to know for 2026. For a deeper dive, see our full Premium Tax Credits & Subsidies guide.
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Who qualifies
Households earning between 100% and 400% of the Federal Poverty Level (FPL). Enhanced subsidies introduced in 2021 extended eligibility above 400% FPL — meaning many middle-income Floridians may still qualify for some level of subsidy.
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How they're calculated
The subsidy is based on the cost of the benchmark Silver plan in your area. The government caps how much of your income you're expected to spend on coverage — anything above that cap is subsidized.
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2026 income examples (individual)
At $20,000/year (~138% FPL): monthly premium after subsidy could be $0–$20. At $35,000/year (~240% FPL): premiums are significantly reduced. At $60,000/year (~412% FPL): some subsidy may still apply depending on your county's benchmark plan cost.
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Cost-Sharing Reductions (CSR)
If you earn under 250% FPL AND choose a Silver plan on the Marketplace, you may qualify for reduced deductibles and out-of-pocket maximums — a significant additional benefit only available on-exchange.
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ACA plans are organized into four metal tiers — Bronze, Silver, Gold, and Platinum. The tier determines how costs are split between you and the insurer. It has nothing to do with the quality of care.
| ● Bronze — 60% insurer / 40% you |
| Lowest monthly premium, highest out-of-pocket costs. Best for people who are generally healthy and want protection mainly against catastrophic events. Deductibles are typically high — often $5,000–$8,700. |
| ● Silver — 70% insurer / 30% you |
| The benchmark tier for subsidy calculations. If you qualify for Cost-Sharing Reductions (CSR) — available to those earning under 250% FPL — Silver plans can become dramatically more valuable, with deductibles as low as $0–$500. Always check if you qualify for CSR before choosing Bronze. |
| ● Gold — 80% insurer / 20% you |
| Higher monthly premium, lower out-of-pocket costs. Best for people who use medical services regularly, take ongoing prescriptions, or have chronic conditions. The higher premium is often offset by lower deductibles and copays throughout the year. |
| ● Platinum — 90% insurer / 10% you |
| Highest monthly premium, lowest out-of-pocket costs. Best for people with significant ongoing medical needs who want maximum cost predictability. Less common in Florida's individual market. |
Within each metal tier, plans come in different network structures that determine which doctors you can use and whether you need referrals.
| Plan Type | What It Means |
| HMO Health Maintenance Org. |
Requires a primary care physician (PCP) who coordinates your care and provides referrals to specialists. Must stay in-network except for emergencies. Pros: Lower premiums, less paperwork. Cons: Less flexibility, referrals required. |
| PPO Preferred Provider Org. |
No PCP requirement, no referrals needed. See any doctor — in-network for lower costs or out-of-network at higher cost. Pros: Maximum flexibility. Cons: Higher premiums, more complex cost-sharing. |
| EPO Exclusive Provider Org. |
No referrals needed, but must stay in-network for all non-emergency care. Pros: No referrals, lower premiums than PPO. Cons: No out-of-network coverage at all. |
| HDHP High Deductible Health Plan |
Any plan with a deductible of at least $1,700 (individual) in 2026. Main advantage: eligible to be paired with a Health Savings Account (HSA) for a triple-tax advantage. Pros: Lower premiums, HSA-eligible. Cons: Higher deductible before coverage kicks in. |
ACA Marketplace plans aren't the only option for every situation. Depending on your circumstances, one of these alternatives may be a better fit.
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Designed to bridge a gap in coverage — between jobs, after missing Open Enrollment, or while waiting for employer coverage to start. Can become effective as soon as the next day. Not ACA-compliant. Excludes pre-existing conditions. In Florida, initial terms up to 364 days with total duration up to 36 months. Typically much lower premium than ACA plans.
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Medicaid
Florida's Medicaid program provides free or very low-cost health coverage to eligible low-income adults, children, pregnant women, and people with disabilities. Florida has not expanded Medicaid under the ACA, so childless adults have limited eligibility. Apply through ACCESS Florida at myflorida.com.
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COBRA Continuation Coverage
Allows you to continue your former employer's health plan after leaving a job — same doctors, same network — but you pay the full premium yourself, often making it significantly more expensive than Marketplace alternatives. Duration: up to 18 months in most cases.
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Standard health insurance does not cover routine dental or vision care. Standalone dental and vision plans fill this gap and are available year-round with no Open Enrollment restriction. NISONA offers plans from Florida Blue Dental, Delta Dental, MetLife, Humana, and others.
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Health insurance has specific enrollment windows. Outside of these windows, you generally cannot buy an ACA Marketplace plan unless you qualify for a Special Enrollment Period.
| Enrollment Window | Details |
| Open Enrollment Period | November 1 through January 15 in Florida. Anyone can enroll regardless of health status. Enrolling by December 15 ensures coverage starts January 1. |
| Special Enrollment Period | A 60-day window triggered by a qualifying life event — losing job-based coverage, getting married or divorced, having a baby, moving, or losing Medicaid eligibility. Don't let the 60-day window lapse. |
| Medicaid / CHIP | If your income qualifies you for Medicaid or the Children's Health Insurance Program (CHIP), you can apply any time of year — no enrollment window restriction. Apply through ACCESS Florida at myflorida.com. |
| Short-Term Plans | Temporary / short-term health insurance can be purchased at any time of year with coverage starting as soon as the next day. Use as a bridge if you've missed Open Enrollment and don't have a qualifying event. |
Health insurance decisions are some of the most financially consequential choices you'll make each year. Having an experienced, independent advisor in your corner costs you nothing and can save you hundreds.
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✓ Independent & Unbiased
NISONA represents multiple carriers — not just one. We compare every plan available in your county and recommend the one that actually fits your situation.
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✓ Subsidy Expertise
Navigating premium tax credits, cost-sharing reductions, and on-exchange vs. off-exchange tradeoffs is complex. We do this every day and know how to maximize your subsidy eligibility.
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✓ No Cost to You — Ever
Our service is completely free. We're compensated by the insurance carriers when you enroll — at no additional cost to you and with no impact on your premium.
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✓ Local to Florida's Treasure Coast
Based in Sebastian, FL, we understand your local carrier networks, regional hospitals, and the specific plans available in Indian River, Brevard, and surrounding counties.
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| Florida Health Insurance — Hub Page | Temporary Health Insurance |
| Dental & Vision Insurance | Health Savings Accounts (HSA) |
| Critical Illness & Cancer Plans | Overseas Travel Insurance |
Free, no-pressure consultation — we'll check your subsidy eligibility, compare every plan available in your area, and help you make a confident health insurance decision.
| Get a Free Consultation → | Get an Instant Quote |
📞 772-770-0700 | (888) 564-2326 | 1627 US Hwy 1, Suite 220, Sebastian, FL 32958
This guide is for general informational purposes only and reflects health insurance program details as of 2026. Premiums, subsidies, and plan availability vary by county and income. NISONA is an independent insurance agency and is not affiliated with or endorsed by the U.S. Government, the ACA Marketplace, or any individual carrier. Always confirm current plan details with a licensed advisor before enrolling.
Nisona serves the insurance needs of the Treasure and Space Coast.