Health insurance questions, answered

Yes. Under the Affordable Care Act, Marketplace and other ACA-compliant health plans cannot deny you coverage, charge you more, or exclude treatment because of a preexisting condition. That protection is one of the biggest differences between ACA-compliant plans and alternatives like short-term coverage, which can decline applicants or exclude conditions — an important trade-off to understand before choosing.

Marketplace subsidies — officially, premium tax credits — lower your monthly premium based on your household income and size. Many people are surprised to learn they qualify: depending on your income, the credit can cover a meaningful share of your premium. The catch is that your estimate matters — if you understate your income, you may owe money back at tax time, and if you overstate it, you may be leaving savings unclaimed. Getting the estimate right, and choosing a plan that makes the most of it, is a big part of what I help with.

You may still have options. A Special Enrollment Period may open when life changes — losing employer coverage, marriage, divorce, a new baby, or a permanent move, among other qualifying events — depending on the event and circumstances; a move, for instance, generally also requires that you had qualifying coverage before it. If you don't qualify for a Special Enrollment Period, short-term coverage can bridge the gap until the next open enrollment, with the caveat that it doesn't carry the ACA's protections.

The individual Marketplace at healthcare.gov is where most self-employed people and 1099 workers end up, and being self-employed does not disqualify you from a premium tax credit — eligibility turns on your household income and size, not on having an employer. The part worth planning for is that your income may be uneven across the year, and the credit is based on what you ESTIMATE for the year ahead and then reconciled at tax time. If you have a strong year, you can owe some of it back. Updating your estimate on healthcare.gov during the year, rather than waiting until you file, is the practical habit here.

Losing job-based coverage generally opens a Special Enrollment Period, and the window is limited — so this is one to act on rather than think about. You can also compare it against COBRA, which continues your existing plan but at the full cost. They are genuinely different trade-offs and the right answer depends on your household's income and which doctors you want to keep. Our post on [what happens to your health insurance when you leave a job](/blog/job-loss-health-coverage) walks through the comparison.

No. A household can be covered in more than one way at the same time — for example, children may qualify for NC Medicaid or CHIP while a parent takes a Marketplace plan, and one spouse may be on employer coverage while the rest of the family is not. The Marketplace application can assess eligibility for Marketplace savings and may send eligible household members to the state for Medicaid or CHIP review, which is why it is worth applying as a household even if you expect only some of you to qualify.

You'll never receive a bill from me. Like most health insurance agents, I'm compensated by the insurance carriers when I help someone enroll, and your premium is exactly the same whether you enroll through me, directly with the carrier, or on healthcare.gov. The difference is that you get an advisor who works with multiple carriers, explains the trade-offs in plain English, and picks up the phone after you've enrolled.

Open Enrollment typically begins November 1. Dates and deadlines are set federally and can change, so confirm the current schedule directly at HealthCare.gov before you enroll rather than assuming last year's date still applies.

If you have Marketplace coverage in December and take no action by December 15, HealthCare.gov may automatically re-enroll you — possibly in your current plan, possibly in a different plan from the same insurer, or in another insurer's plan if yours is no longer offered in your area. Re-enrollment is not guaranteed and it is not a review: it can carry forward an income estimate or household size that is no longer accurate, and your coverage still depends on paying the first premium by your plan's deadline.

Not necessarily. Your credit is recalculated each year from your estimated household income, household size, and the cost of the benchmark plan in your area — and that benchmark changes annually even if nothing about your household has. If you don't update your income estimate, you could end up with more or less savings than you actually qualify for, and owe the difference back at tax time.

No. North Carolina uses the federal HealthCare.gov platform rather than a state-run exchange, so enrollment, income updates, and premium tax credit eligibility all run through HealthCare.gov directly.

Several insurers have filed requests with the NC Department of Insurance for higher 2027 individual ACA rates. Those are opening positions, not decisions — NC DOI's own disclosure page states that final rates may differ from what was initially filed and will be posted later. Until the department publishes approved rates, there is no 2027 number worth planning around.

No. A filed change applies to a carrier's overall book of business, not to any one person's bill. What you actually pay depends on your age, tobacco use, where in North Carolina you live, which plan and metal tier you choose, and any premium tax credit you qualify for — which is worked out from your household size and estimated household income against a benchmark plan in your area, not from income alone.

No date has been announced for 2027. As a timing reference, NC DOI announced final approved rates for the 2026 plan year on October 29, 2025, shortly before that year's enrollment window opened November 1. The department sets its own schedule each year, so confirm at ncdoi.gov or HealthCare.gov rather than assuming the same date repeats.

Re-shop your options rather than letting your plan auto-renew, and update your household income estimate on healthcare.gov before you enroll. Your premium tax credit is not set by income alone — it is worked out from your household size and estimated household income against the cost of a benchmark plan in your area, and that benchmark is recalculated each year. So your credit can move even when nothing about your household has changed, which means the plan that fit best last year may not be the one that fits this year.

The metal level describes how you and the plan share costs for covered services, not the quality of care. HealthCare.gov estimates the plan's share at about 60% for Bronze, 70% for Silver, 80% for Gold, and 90% for Platinum, with you paying the rest. These percentages describe average covered costs across a standard population, not the share the plan will necessarily pay for your own care over a year. What you actually pay depends on the specific plan's deductible, copays, coinsurance, and out-of-pocket maximum.

Yes. If you qualify for income-based cost-sharing reductions, you need to choose a Silver plan to get them. These savings can reduce deductibles, copays or coinsurance, and the out-of-pocket maximum. They are separate from the premium tax credit.

Per HealthCare.gov, catastrophic plans are for people under 30, or people 30 and older who qualify for a hardship or affordability exemption. They cover at least three primary care visits a year before the deductible. You cannot use a premium tax credit toward a catastrophic plan. If you qualify for a credit, compare the actual premiums after that credit for Bronze and Silver plans before deciding.

No. HealthCare.gov states that the metal categories have nothing to do with the quality of care you get. The level describes how costs are split. Which doctors and hospitals you can use depends on the specific plan's network, which you check plan by plan.

It's a credit that lowers what you pay each month for a Marketplace health plan. The amount depends on your estimated household income, your household size, and the cost of the benchmark Silver plan where you live. You can choose to use all, some, or none of it in advance; whatever you use in advance goes straight to the insurer and lowers your monthly premium. You then reconcile the estimate against your actual income when you file, using Form 8962.

If your actual income comes in higher than your estimate, you may need to repay some or all of the advance credit you received. If it comes in lower, you may get an additional credit on your refund. For tax years after 2025, there's no longer a cap limiting how much you'd have to repay if you underestimated — a protection that existed for years is gone.

Yes. From 2021 through 2025, a temporary expansion removed the income cap on premium tax credit eligibility. That expansion expired, so the standard rule is back: household income above 400% of the federal poverty line generally makes you ineligible for any premium tax credit, and any advance payments you received would need to be repaid in full.

No. North Carolina uses the federal healthcare.gov platform rather than a state-run exchange, so Marketplace enrollment, income estimates, and premium tax credit eligibility all run through healthcare.gov directly.

Healthcare.gov groups them into a few categories: losing other health coverage (a job, COBRA, Medicaid, a parent's plan), household changes (marriage, birth or adoption — and divorce or a death where it causes you to lose coverage, which is the condition people miss), moving to a new address, and a handful of others like gaining citizenship or leaving incarceration. Each has its own rules and its own proof requirements, so confirm your specific event at HealthCare.gov.

Most Special Enrollment Periods run 60 days, often before or after the event depending on the type, but the exact window, proof requirements, and plan choices vary by event — HealthCare.gov's SEP screening tool will point you to the rules for your situation, and the Marketplace makes the actual eligibility determination when you apply.

Losing job-based coverage generally qualifies, but the trigger is losing the coverage itself, not just leaving the job — and electing COBRA and later dropping it early is treated differently than letting COBRA run its full course. Our COBRA vs. Marketplace comparison walks through that distinction.

No. Medicare has its own separate set of Special Enrollment Periods with different triggers and timing than the ACA Marketplace. If you're within a few years of 65, treat them as two different systems and check the Medicare-specific rules at Medicare.gov.

It depends on cost, timing, and whether keeping your current plan and network matters right now. COBRA continues your old employer plan but you generally pay the full premium plus up to a 2% fee. A Marketplace plan is a new policy, and its cost may be lowered by a premium tax credit worked out from your household size and estimated household income together, not from income alone. Compare both before choosing — the decision isn't automatically the same for everyone.

It depends on how you leave COBRA. Voluntarily dropping COBRA partway through its term generally does NOT open a Marketplace Special Enrollment Period. Letting COBRA run out at the end of its full term generally does. That distinction is easy to miss and can leave you without a path to switch until the next Open Enrollment.

For COBRA, you generally must be given an election period of at least 60 days, starting from the later of the date you receive the election notice or the date your coverage would otherwise end. Losing job-based coverage also generally opens a Marketplace Special Enrollment Period, but the exact window and required proof depend on your situation — confirm the current rules on healthcare.gov.

It depends on the plan you pick and on your household — size as well as income. COBRA has a predictable cost structure — the full premium plus up to a 2% administrative fee. A Marketplace plan's cost varies by the plan you choose and may be reduced by a premium tax credit if your income qualifies, which isn't available through COBRA. Comparing both with real numbers is worth doing before you assume either is the cheaper option.

Generally three: continue your employer plan through COBRA (if your employer had 20 or more employees), enroll in a Marketplace plan through a Special Enrollment Period, or — for a short, defined gap — a short-term plan. Each has real trade-offs in cost, coverage, and timing.

Under federal law you generally must be given at least 60 days to elect COBRA, starting from the later of the date you're sent the election notice or the date your coverage would otherwise end. Employers with fewer than 20 employees generally aren't required to offer COBRA at all.

Losing job-based coverage generally opens a Special Enrollment Period on healthcare.gov — the window and required proof depend on your specific situation, so confirm the details directly on healthcare.gov rather than assuming a generic timeline.

Often, yes. Under COBRA you can be charged the full cost of the coverage plus up to a 2% administrative fee, since your former employer stops subsidizing the premium. A Marketplace plan's cost depends on the plan you pick and whether you qualify for a premium tax credit based on income — it's worth comparing both before assuming either is the cheaper option.

It pays the amounts listed in its benefit schedule when a covered event happens, such as a day in the hospital or, in some individual-market plans, a covered service. It does not pay a share of your actual bill. What triggers a payment is a listed event or service — a covered hospital stay can trigger a daily benefit even if the treatments during it aren't listed one by one. Whether a particular event pays depends on the policy's definitions, waiting periods, limitations and exclusions.

The benefit doesn't grow to match a larger bill. CMS describes fixed indemnity benefits as paid regardless of the expenses you incur, so what you still owe depends on what your other insurance pays and any network discount. You can put the cash toward that remaining amount, but it may not cover all of it.

No. CMS says fixed indemnity coverage is not a substitute for comprehensive coverage, and NC DOI says hospital indemnity policies should not be used as a substitute for comprehensive health insurance. These plans are designed to complement comprehensive coverage, not replace it.

They pay in different ways. A short-term health plan is temporary coverage that generally pays a share of covered medical bills, subject to its deductible, limits and exclusions, and in North Carolina it can last no more than four months in total. A fixed indemnity plan pays a set amount written into its benefit schedule when a covered event happens, regardless of what the bill turns out to be.

No. It pays scheduled amounts per day or per covered service rather than covering the bill itself, so it isn't built to cap what a serious year could cost you. If a bill is larger than the benefit, you generally remain responsible for whatever neither your other health coverage nor the fixed benefit pays.

North Carolina follows the federal definition of short-term, limited-duration insurance, which allows no more than four months in total, including any renewal or extension. NC DOI Bulletin 25-B-11 confirmed the state will keep following that definition even though federal agencies said in August 2025 they would not prioritize enforcing it.

Neither is built to. Neither one is an ACA Marketplace plan, so neither is eligible for the premium tax credit. Both may ask health questions, and approval can depend on your health history. The usual first step is finding out what a Marketplace plan would cost you after any premium tax credit, then deciding whether either of these has a role.

It depends on your situation. A short-term plan can be a reasonable, lower-cost way to bridge a short coverage gap if you're healthy with no ongoing medical needs, but these plans use medical underwriting, typically exclude pre-existing conditions, and don't carry the ACA's guaranteed-issue protections — so they're rarely a good substitute for ongoing coverage.

Short-term plans generally aren't required to cover the ACA's essential health benefits, so maternity care, mental health and substance-use treatment, and prescription drugs are often limited, excluded, or capped. Pre-existing conditions are also typically excluded.

Yes. Unlike ACA-compliant Marketplace plans, short-term plans use medical underwriting, meaning an insurer can decline your application outright or exclude coverage for a condition you already have.