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.
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Key Points
Before comparing plans, it helps to understand the six terms that determine what you actually pay.
Your monthly payment to keep coverage active — whether or not you use any medical services. Subsidies can reduce this significantly based on your income.
What you pay out-of-pocket each year before your insurer starts sharing costs. Example: with a $2,000 deductible, you pay the first $2,000 in medical bills yourself.
A fixed amount you pay for a specific service — like $30 for a doctor visit or $15 for a prescription — sometimes before or after your deductible is met, depending on the plan.
After your deductible is met, you and your insurer split costs by percentage. With 80/20 coinsurance, your insurer pays 80% and you pay 20% until you hit your 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 2026, ACA plans cap this at $9,200 (individual) / $18,400 (family).
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, depending on your plan type.
This is one of the most misunderstood areas of health insurance — and one of the most financially important. Where you buy your plan determines whether you can access federal subsidies that could save you hundreds of dollars per month.
What is the ACA Marketplace? The Health Insurance Marketplace (also called “the exchange” or “Obamacare”) is a government-run platform at HealthCare.gov where you can shop for ACA-compliant health insurance. Plans sold here are “on-exchange.” This is the only place you can access premium tax credits.
| On-Exchange (Marketplace) | Off-Exchange (Direct) | |
|---|---|---|
| Premium tax credits | ✓ Available if income-eligible | ✗ Not available |
| Cost-sharing reductions | ✓ On Silver plans | ✗ Not available |
| ACA compliance | ✓ Required | ✓ Most plans still ACA-compliant |
| Where you buy | HealthCare.gov or licensed broker | Directly from insurer or broker |
| Best for | Anyone who may qualify for subsidies | Higher earners with no subsidy eligibility |
⚠ Critical warning: If you buy an identical plan directly from an insurer (off-exchange), you lose access to premium tax credits entirely — even if you would have qualified. Always check your subsidy eligibility before buying off-exchange. A NISONA advisor can run this comparison for you in minutes at no cost.
Premium tax credits are federal subsidies that reduce your monthly health insurance premium. They’re based on your estimated annual household income.
Available to households earning between 100% and 400% of the Federal Poverty Level (FPL) — and enhanced subsidies introduced in 2021 extended eligibility above 400% FPL, meaning many middle-income Floridians qualify for some level of subsidy.
The credit is calculated based on the cost of the benchmark Silver plan in your area. The government caps what percentage of your income you’re expected to spend — anything above that cap is subsidized.
If your income is below 250% FPL AND you choose a Silver plan on the Marketplace, you may also qualify for reduced deductibles and out-of-pocket maximums — a significant additional benefit available only on Silver plans, only on-exchange.
With the highest CSR tier (under ~138% FPL), your Silver plan deductible could be as low as $0–$100 instead of the standard $3,000–$4,000.
| Annual Income (Individual) | % of FPL (approx.) | Subsidy Eligibility |
|---|---|---|
| Under $21,000 | Under ~145% FPL | Premium credit + CSR (Silver plan) |
| $21,000–$36,000 | ~145%–250% FPL | Premium credit + possible CSR |
| $36,000–$58,000 | ~250%–400% FPL | Premium credit (no CSR) |
| Above $58,000 | Above ~400% FPL | Partial credit may still apply — check eligibility |
Income thresholds are approximate and based on 2026 Federal Poverty Level guidelines. Exact subsidy amounts depend on household size, location, and plan selected.
ACA plans are organized into four “metal” tiers that determine how costs are split between you and your insurer. The tier has nothing to do with the quality of care — only the cost-sharing structure.
| BRONZE 60/40 split |
Lowest monthly premium, highest out-of-pocket costs when you use care. Best for people who are generally healthy and want protection mainly against catastrophic events. Deductibles are typically $5,000–$8,700. |
| SILVER 70/30 split |
The benchmark tier for subsidy calculations. If you qualify for Cost-Sharing Reductions (under 250% FPL), Silver plans can be dramatically better value — with deductibles as low as $0–$500 instead of the standard $3,000+. Always check CSR eligibility before choosing Bronze. |
| GOLD 80/20 split |
Higher monthly premium, lower out-of-pocket costs when you use care. Best for people who use medical services regularly, take ongoing prescriptions, or have chronic conditions. The higher premium is often offset by much lower annual costs. |
| PLATINUM 90/10 split |
Highest monthly premium, lowest out-of-pocket costs. Insurer covers 90% of costs after deductible. 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 see and whether you need referrals.
Requires a primary care physician (PCP) and referrals to see specialists. Must stay in-network except for emergencies.
Pros: Lower premiums, lower out-of-pocket costs
Cons: Referrals required, no out-of-network coverage
No PCP required, no referrals needed. See any doctor in or out of network — in-network for lower costs, out-of-network at higher cost.
Pros: Maximum flexibility, no referrals
Cons: Higher premiums
No referrals needed (like PPO), but must stay in-network for all non-emergency care (like HMO).
Pros: No referrals, lower premiums than PPO
Cons: Zero out-of-network coverage
Any plan with a deductible of at least $1,700 (individual) in 2026. The key benefit: you can pair it with a tax-advantaged Health Savings Account (HSA).
Pros: Lower premiums, HSA-eligible
Cons: Higher deductible before coverage kicks in
ACA Marketplace plans aren’t the only option for every situation.
Designed to bridge a coverage gap — between jobs, after missing Open Enrollment, or while waiting for employer coverage to start. Not ACA-compliant, excludes pre-existing conditions, but can start as soon as the next day. In Florida, initial terms up to 364 days with total duration up to 36 months. Learn more about temporary health insurance →
Free or very low-cost coverage for eligible low-income adults, children, and pregnant women. Florida has not expanded Medicaid under the ACA, so eligibility for childless adults is limited. Apply through ACCESS Florida at myflorida.com any time of year.
Continue your former employer’s health plan after leaving a job. Keeps the exact same coverage but you pay the full premium yourself — often significantly more expensive than alternatives. Compare COBRA vs. temporary insurance →
A tax-advantaged savings account available to people enrolled in a qualifying HDHP. Triple tax benefit: contributions are deductible, growth is tax-free, and withdrawals for medical expenses are tax-free. 2026 contribution limits: $4,400 (individual) / $8,750 (family). Learn more about HSAs →
Health insurance has specific enrollment windows. Outside these windows, you generally cannot buy an ACA Marketplace plan unless you qualify for a Special Enrollment Period.
November 1 – January 15 (Florida federal Marketplace). Anyone can enroll or change plans during this window regardless of health status. Enroll by December 15 for January 1 coverage.
60 days from a qualifying life event — losing job-based coverage, getting married or divorced, having a baby, or moving. Don’t let this 60-day window lapse.
If your income qualifies you for Medicaid or CHIP, you can apply any time of year — no enrollment window restriction. Apply at myflorida.com.
Temporary health insurance can be purchased any time of year, starting as soon as the next day. Use as a bridge if you’ve missed Open Enrollment without a qualifying event.
Almost always on-exchange, unless you earn too much to qualify for any subsidy (generally over $58,000/year for an individual). Even if you think you don’t qualify, check first — many people are surprised. A NISONA advisor can run this in minutes at no cost.
It depends on the plan’s network. Before enrolling, confirm your doctor is in-network for the specific plan — not just the carrier. A doctor can be in-network for one Humana plan and out-of-network for another Humana plan.
Yes — self-employed individuals can enroll through the Marketplace and qualify for premium tax credits based on estimated annual net income. Business expenses reduce your income for subsidy purposes, often meaning a larger subsidy than expected.
Without a qualifying life event, you generally can’t enroll in a Marketplace plan until next Open Enrollment. Options include temporary/short-term health insurance (available year-round), Medicaid if you qualify, or COBRA if you recently left a job with coverage.
No federal penalty as of 2019. However, going uninsured means paying 100% of medical costs yourself — which can be financially devastating if you experience a serious illness or accident.
Free Resource
Take everything on this page with you — our free PDF guide covers all of this in a clean, printable format. No email required, no sign-up, just download.
✓ Key Terms
Premium, deductible, coinsurance, OOP max
✓ On vs. Off Exchange
Subsidies, CSR, and how to maximize your benefit
✓ Metal Tiers & Plan Types
Bronze through Platinum, HMO vs PPO vs EPO
⬇ Download the Free Guide (PDF)
No email required. No sign-up. Just download and read.
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