ACA plans are health insurance policies that comply with the standards set by the Affordable Care Act, the 2010 federal law that reshaped how health coverage works in the United States. These plans must cover a minimum set of benefits, accept everyone regardless of health history, and cap what you can spend out of pocket each year. You can buy them through the federal or state health insurance marketplaces, and many people qualify for financial help to lower costs.
What ACA Plans Must Cover
Every ACA-compliant plan is required to include 10 categories of essential health benefits. These are doctors’ visits, inpatient hospital care, outpatient services, prescription drugs, pregnancy and childbirth, mental health and substance use treatment, rehabilitative services, lab tests, preventive care and wellness, and pediatric services including dental and vision for children.
Beyond those categories, ACA plans must provide a set of preventive services at zero cost to you when you see an in-network provider. That means no copay or coinsurance for things like immunizations, cancer screenings, blood pressure checks, and cholesterol tests, even if you haven’t met your deductible yet. Separate lists of covered preventive services exist for adults, women, and children.
Pre-Existing Condition Protections
Before the ACA, insurers could deny you coverage, charge you more, or exclude treatment for health problems you already had. That’s no longer legal. ACA plans cannot refuse coverage or raise your premium because of a pre-existing condition like diabetes, asthma, cancer, or pregnancy. Once you’re enrolled, they also can’t limit benefits or refuse to cover treatment related to that condition. The one exception: “grandfathered” plans that existed before the law took effect and haven’t made significant changes don’t have to follow this rule.
Metal Tiers and Cost Sharing
ACA marketplace plans are organized into four tiers named after metals. The tier tells you roughly how costs are split between you and the insurer:
- Bronze: The plan pays about 60% of covered healthcare costs, you pay 40%. Monthly premiums are the lowest, but you’ll pay more when you actually use care.
- Silver: The plan pays about 70%, you pay 30%. Silver plans are the only tier eligible for extra savings that can push the plan’s share as high as 94% to 96% for lower-income enrollees.
- Gold: The plan pays about 80%, you pay 20%. Higher premiums, but less financial exposure when you need care.
- Platinum: The plan pays about 90%, you pay 10%. The highest premiums, but the lowest costs at the point of care.
These percentages are averages across all enrollees in that plan type, not a guarantee of your exact split. Your actual costs depend on the specific services you use and how your plan structures deductibles, copays, and coinsurance.
Catastrophic Plans
There’s also a fifth option below the metal tiers. Catastrophic plans have very low premiums but very high deductibles, and they’re designed mainly to protect you from worst-case medical bills. Eligibility is limited to people under 30, or those over 30 who qualify for a hardship or affordability exemption because marketplace or job-based coverage is unaffordable for them.
Out-of-Pocket Limits
One of the most important features of ACA plans is a hard cap on what you can be asked to pay in a given year. For 2025, that cap is $9,200 for an individual and $18,400 for a family. Once your deductibles, copays, and coinsurance hit that ceiling, the plan covers 100% of covered services for the rest of the year. Plans sold outside the ACA marketplace don’t always have this protection.
Financial Help With Premiums and Costs
Many people who buy marketplace plans qualify for premium tax credits that lower monthly payments. To be eligible, your household income generally needs to be at least 100% of the federal poverty level. For 2021 and 2022, Congress temporarily removed the upper income cap of 400% of the poverty level, and subsequent legislation has extended that expanded eligibility. The credit is applied directly to your monthly bill so you don’t have to wait for a tax refund.
If your income is on the lower end, you may also qualify for cost-sharing reductions, which lower your deductibles and copays. These reductions only apply to Silver-tier plans, which is why Silver plans with extra savings can cover anywhere from 73% to 94% or more of your costs instead of the standard 70%.
Network Types in ACA Plans
ACA plans use the same network structures found in employer-sponsored insurance. The type of network affects which doctors and hospitals you can see and what you’ll pay for out-of-network care.
- HMO (Health Maintenance Organization): Covers care only from providers in the plan’s network, except in emergencies. May require you to live or work in a specific service area.
- PPO (Preferred Provider Organization): You can see providers outside the network without a referral, but you’ll pay more for it. Offers the most flexibility.
- EPO (Exclusive Provider Organization): Similar to an HMO in that out-of-network care isn’t covered except in emergencies, but you typically don’t need referrals to see specialists.
- POS (Point of Service): A hybrid. You pay less for in-network care, but you can go out-of-network at higher cost. Seeing a specialist requires a referral from your primary care doctor.
Before choosing a plan, it’s worth checking whether your current doctors and preferred hospitals are in the plan’s network. The cheapest premium doesn’t save you money if you end up paying full price for out-of-network visits.
Where to Buy ACA Plans
You can purchase ACA plans through the Health Insurance Marketplace. Most states use the federal platform at HealthCare.gov, but 21 states and the District of Columbia run their own exchanges with separate websites and enrollment systems. States with their own marketplaces include California, New York, Colorado, Massachusetts, Pennsylvania, Virginia, and others. A few states, like Arkansas and Oregon, run their own exchanges but use the federal platform for enrollment.
You can also buy ACA-compliant plans directly from insurance companies or through brokers outside the marketplace, but doing so means you won’t have access to premium tax credits or cost-sharing reductions. Those financial subsidies are only available through the marketplace.
Enrollment Periods
ACA marketplace plans follow an annual enrollment cycle. Open Enrollment typically starts November 1 and runs through January 15. If you want coverage starting January 1, the deadline to enroll or switch plans is December 15. Enrolling between December 16 and January 15 generally means your coverage begins February 1.
Outside of Open Enrollment, you can only sign up or change plans if you qualify for a Special Enrollment Period. Qualifying events include losing other health coverage, moving to a new area, getting married, having a baby, or adopting a child. These events typically give you 60 days to enroll. State-run marketplaces sometimes set their own dates, so if your state operates its own exchange, check its website for specific deadlines.