Coverage guide
How health insurance works, in plain English
Where coverage comes from, the terms you'll see on every plan, and how plan types differ. Read it before you compare, or keep it open while you do.
- Open Enrollment (HealthCare.gov)
- Nov 1, 2026 – Jan 15, 2027
- Special Enrollment
- Usually 60 days after a life event
- Plan types
- HMO · PPO · EPO · POS
Ways to get coverage
Where health coverage comes from
Most people get coverage in one of four ways. Which one fits depends on your work, age, income and household.
| Coverage | Usually for | How ProtecWise can help |
|---|---|---|
| Marketplace plan | Usually forPeople who buy their own coverage, including the self-employed and anyone without an offer of affordable job-based coverage. Premium tax credits may lower the cost based on income. | How ProtecWise can helpLive quotes for your ZIP code, side-by-side comparison and enrollment help. Compare plans |
| Employer plan | Usually forEmployees, and often their spouses and dependents, offered coverage through work. | How ProtecWise can helpIf you're leaving a job or losing job-based coverage, we can help you compare Marketplace options. |
| Medicare | Usually forPeople 65 and older, and some younger people with certain disabilities or conditions. | How ProtecWise can helpPlain-English education on the parts of Medicare and when you can enroll. Medicare basics |
| Medicaid & CHIP | Usually forPeople and families with limited income. CHIP covers children in families that earn too much for Medicaid. Rules vary by state. | How ProtecWise can helpA Marketplace application shows whether your household may qualify, and you can apply any time of year. |
Key terms
The words on every plan
Premiums are what you pay to have coverage. The rest decide what you pay when you use it.
- Premium
- The amount you pay each month to keep your plan active, whether or not you use care.
- Deductible
- What you pay for covered services each year before your plan starts to share the cost. Many plans cover some preventive care before you meet it.
- Copay
- A fixed dollar amount you pay for a covered service, such as a doctor visit or a prescription.
- Coinsurance
- Your share of the cost of a covered service as a percentage, such as 20%, usually after you meet your deductible.
- Out-of-pocket maximum
- The most you pay for covered, in-network care in a plan year. After you reach it, the plan pays 100% of covered services.
- Network
- The doctors, hospitals and pharmacies that contract with your plan. Staying in network usually costs less.
- Metal tier
- Bronze, Silver, Gold and Platinum describe how a Marketplace plan splits average costs with you, not the quality of care.
Plan types
HMO, PPO, EPO and POS
Plan type sets the rules for which doctors you can see and whether you need a referral. Check the plan's own documents for the details.
| Type | Network | Specialist referrals | Out-of-network care |
|---|---|---|---|
| HMO | NetworkHealth Maintenance Organization. You use the plan's network. | Specialist referralsUsually required | Out-of-network careGenerally not covered, except emergencies |
| PPO | NetworkPreferred Provider Organization. Lower costs in network. | Specialist referralsUsually not required | Out-of-network careCovered, at a higher cost |
| EPO | NetworkExclusive Provider Organization. You use the plan's network. | Specialist referralsUsually not required | Out-of-network careGenerally not covered, except emergencies |
| POS | NetworkPoint of Service. Lower costs in network. | Specialist referralsUsually required | Out-of-network careCovered at a higher cost, often with a referral |
Plans, benefits and availability vary by location and carrier. Estimated premiums and financial assistance are subject to an official eligibility determination by the applicable Marketplace.
Ready to compare plans?
See live Marketplace plans and estimated costs for your household, with a licensed agent available if you want help.