US Health Insurance Explained: Marketplace, Employer Plans, and the Basics

Key Terms (Learn These First)

• Premium: what you pay each month for the plan, whether or not you use care.
• Deductible: what you pay out of pocket each year before insurance starts paying (e.g., $2,000).
• Copay: a flat fee per visit (e.g., $30 for a PCP visit).
• Coinsurance: your percentage share after the deductible (e.g., 20%).
• Out-of-pocket maximum: the most you will pay in a year for covered services — after this, the plan pays 100%. This is your real worst-case number.

ACA Marketplace (healthcare.gov)

If your employer does not offer insurance (or you are self-employed), buy through the ACA marketplace:

• Open enrollment: November 1 – January 15 each year (enroll by December 15 for coverage starting January 1).
• Subsidies: premium tax credits lower your monthly cost based on income — most marketplace enrollees qualify for some subsidy.
• Special enrollment: outside open enrollment, you can enroll after qualifying life events — losing other coverage, moving, marriage, having a baby, and (for many immigrants) gaining lawfully-present status.
• Medicaid/CHIP: if your income is low, the marketplace will route you to Medicaid, which accepts applications year-round.

Newcomer note: lawfully present immigrants (green card holders, asylees, visa holders including F-1/H-1B) can buy marketplace plans and may qualify for subsidies. Undocumented immigrants generally cannot.

Employer Plans

Most Americans get insurance through work. Your employer pays part of the premium; you pay the rest pre-tax from your paycheck. During annual open enrollment (usually fall), you pick next year's plan — compare the deductible, out-of-pocket max, and whether your doctors are in-network, not just the premium.

HDHP + HSA: The Triple Tax Break

A High-Deductible Health Plan paired with a Health Savings Account is popular with healthy, higher-income people:

• 2026 HSA contribution limits: $4,400 (self-only) / $8,750 (family), plus $1,000 catch-up at 55+.
• Triple tax advantage: contributions are pre-tax, growth is tax-free, and withdrawals for medical expenses are tax-free.
• The HSA is yours forever — it rolls over year to year and stays with you if you change jobs. (Do not confuse with an FSA, which is use-it-or-lose-it.)

Medicaid and Medicare Basics

• Medicaid: joint federal-state program for low-income people (in expansion states, up to 138% of the federal poverty level). Most immigrants face a 5-year waiting period after getting a green card — with exceptions for refugees, asylees, and some others.
• Medicare: federal insurance for people 65+ (and some with disabilities). Not available to newcomers regardless of age unless they have the required US work history.

COBRA: Keeping Coverage After Job Loss

If you leave a job with 20+ employees, federal COBRA law lets you keep the same employer plan for up to 18 months — but you pay the full premium plus a 2% admin fee, which is often shockingly expensive ($600–1,500+/month for family coverage). Before electing COBRA, compare marketplace plans: losing your job triggers a 60-day special enrollment period, and subsidized marketplace coverage is usually far cheaper. COBRA makes sense mainly as a bridge when you are mid-treatment with specific in-network doctors.

ShareCopied!

Scan with WeChat to share