Choose a health plan and enrol

The overview of the four routes to coverage tells you where insurance comes from. This guide is about the harder part: picking a specific plan and actually getting enrolled before a window closes.

Marketplace window

Open enrollment each autumn, plus 60 days after a qualifying life event

Just arrived?

Moving to the U.S. is itself a qualifying event — the clock starts on arrival

Employer plan

Usually 30 days from your start date

Medicaid / CHIP

No window at all — apply any day of the year

1. Work out which window you are in

Open enrollment for Marketplace plans runs each autumn into January, for coverage starting the following year. Outside it you cannot simply decide to buy a plan.

A special enrollment period (SEP) opens for 60 days after a qualifying life event. The ones that matter most to new arrivals:

• Moving to the United States — this alone qualifies you
• Losing coverage from a job, or a spouse's job
• Marriage, divorce, birth or adoption
• Moving to a different state, or to a different county with different plans
• A change in income that makes you newly eligible for subsidies

Medicaid and CHIP have no enrollment window. If your income is low enough, you can apply on any day of the year, and coverage often backdates. Apply through the Marketplace and it will route you automatically if you qualify.

2. Estimate your income honestly

Marketplace subsidies — the premium tax credit — are calculated from your expected household income for the coverage year, measured against the federal poverty level. For many new arrivals working their first U.S. job, this reduces the premium dramatically. A great many people who assume they cannot afford a plan have never actually run the numbers.

Two things people get wrong:

• Income means the whole household's expected income for the year, not last month's pay slip multiplied by twelve. If you started work in June, say so.
• The credit is reconciled at tax time. You settle up the following spring using Form 1095-A. Underestimate your income badly and you repay the difference; overestimate it and you get money back. Update the Marketplace during the year if your income changes — that is what stops an unpleasant April.

3. Understand the metal tiers

Marketplace plans are labelled Bronze, Silver, Gold and Platinum. The tier describes how the cost is split, not the quality of care:

Tier	Premium	You pay when you use care
Bronze	Lowest	Most
Silver	Middle	Middle
Gold	Higher	Less
Platinum	Highest	Least

4. Compare on total cost, not premium

Work out, for each plan you are considering:

Premium × 12 + what you expect to spend on care, capped by the out-of-pocket maximum.

Then check three things the price does not show:

1. The network. Is the doctor or hospital you want actually in it? A cheap plan with a narrow network is expensive the first time you need it.
2. The drug formulary. If you take a regular medication, search for it by name in the plan's list. The same drug can be $10 on one plan and $300 on another.
3. The out-of-pocket maximum. This is the number that decides what a bad year costs you. It matters more than the premium.

5. If it is an employer plan

You will usually be offered two or three options:

• HMO — cheaper, but you must stay in network and get referrals from a primary care doctor for specialists.
• PPO — more expensive, no referrals needed, some out-of-network coverage.
• HDHP with an HSA — a high deductible paired with a tax-advantaged savings account. Good value if you are healthy and can fund the account; painful if you are not.

Check whether the employer contributes to family coverage as well as your own — many contribute generously for the employee and very little for dependents, which sometimes makes a Marketplace plan better for the rest of the family.

If you leave the job, COBRA lets you keep the plan but you pay the entire premium yourself, which is usually several times what you were paying. Losing job coverage also opens a Marketplace SEP, and that is very often the cheaper option — compare both before defaulting to COBRA.

6. What you need to hand to apply

• Social Security numbers, or ITINs, for everyone applying
• Immigration document numbers for anyone who is not a citizen
• Expected household income for the year, and pay slips or an offer letter
• Details of any coverage already offered by an employer

7. Free help exists

Every state has trained Navigators and certified application counsellors who help you enrol free of charge, in many languages. They are funded to be neutral — unlike a broker, they are not paid per policy sold. Ask the Marketplace to connect you to one rather than paying anybody for help.