Health insurance is a contract between you and an insurance company where you pay a monthly fee (called a premium), and in return the company helps cover the cost of your medical care. Instead of paying the full cost of a doctor visit, surgery, or prescription out of your own pocket, you share the cost with your insurer according to your plan's rules.
Here's how the cost-sharing works. Your plan has a deductible, which is the amount you pay for covered services before your insurance starts contributing. Once you meet your deductible, you pay a portion of costs (coinsurance or a flat copay) and the insurer pays the rest. That continues until you hit your out-of-pocket maximum, the most you'll spend on covered in-network care in a year. After that, your insurance covers 100% of covered costs for the rest of the year. For 2026, the individual out-of-pocket maximum is $10,600 and the family maximum is $21,200.
All ACA Marketplace plans cover 10 Essential Health Benefits, including:
- Preventive care and wellness visits
- Emergency services
- Hospitalization
- Maternity and newborn care
- Prescription drugs
- Mental health and substance use treatment
- Pediatric services, including dental and vision for children
Marketplace plans also protect you from discrimination based on your health history. You can't be denied coverage or charged more because of a pre-existing condition.
Most people get health insurance through an employer, a parent's plan (until age 26), Medicare or Medicaid (for those who qualify), or the ACA Marketplace. If you buy your own coverage through the Marketplace, you may qualify for a premium tax credit to reduce your monthly cost based on your household income.
New to health insurance or just want to make sure you're on the right plan? Call us at (305) 330-1277 or See your plan options and we'll walk you through everything in plain language.
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