You cannot be turned down
An insurer cannot refuse you, exclude a condition, or charge you more because of your medical history. Before this law, a diagnosis could put individual coverage out of reach at any price.
The Affordable Care Act
What the health care law actually changed
Almost everything people call an ACA plan is an ordinary private plan that the law requires to behave in certain ways. Here is what those ways are.
The ACA is a law, not a plan. You do not buy an ACA plan. You buy a plan that has to follow the ACA's rules.
Looking for something else?
A federal programMedicareHealth coverage from the federal government, mostly for people 65 and older. You sign up through Social Security. Pennie has nothing to do with it.Pennsylvania's marketplacePennieThe website where Pennsylvanians actually buy that coverage. It is the only place in the state where a tax credit can lower your premium.
The basics
What you actually need to know
Ten things every plan must cover
Hospital care, prescriptions, emergency care, maternity and newborn care, and mental health and substance use treatment are among the ten required categories. What sits inside each category still varies from plan to plan.
Preventive care has no separate charge
Screenings, immunizations and annual wellness visits are covered without a separate charge to you, as long as you use a provider in your plan's network.
Metal levels are about cost, not quality
Bronze, Silver, Gold and Platinum describe how you and the plan split the bill. Bronze usually means a lower monthly cost and more to pay when you use care. Platinum is the reverse. The metal level tells you nothing about which doctors are in the network.
Help with the premium depends on income
The premium tax credit lowers your monthly bill. It is based on what you expect to earn during the coverage year, not what you earned last year. It gets settled on your tax return, so a guess that turns out badly wrong is corrected later, in either direction.
The second kind of help is Silver only
Cost-sharing reductions lower your deductible and what you pay at the doctor. Unlike the premium tax credit, you only get them on a Silver plan and only within a certain income range. This is why the cheapest monthly premium is often not the cheapest plan overall.
Common questions
The questions people actually ask
Did the bigger subsidies from the last few years go away?
Yes. Larger premium tax credits were in place from 2021 through 2025, and Congress let them expire at the end of 2025. From 2026 the original rules are back, including the cutoff at 400% of the federal poverty level that people call the subsidy cliff. In practice that means earning one dollar over that line can end your premium help completely, so estimating your income accurately matters more than it used to.
What is the federal poverty level, and why does it decide things?
It is an income figure the federal government publishes every year, adjusted for how many people are in your household. Eligibility for premium help, for cost-sharing reductions and for Medical Assistance are all written as percentages of it. Because it changes yearly and depends on household size, the same income can qualify one year and not the next.
My job offers coverage. Can I use Pennie instead?
You can always buy through Pennie. But if your employer's offer counts as affordable and adequate under the law, you generally cannot get a premium tax credit, which usually makes Pennie the more expensive route. Whether an offer counts is a specific calculation, not an opinion, so it is worth checking rather than assuming.
What if my income is low?
Pennie checks that for you. If your household income is low enough, your application points you toward Medical Assistance, which is Pennsylvania's Medicaid program, or toward CHIP for children. Those programs take applications all year, with no enrollment window.
Which one is yours?
A rough map, not a recommendation
Enough to tell you which system you are dealing with and which official source to read. It is not advice about your situation, and nobody should treat it as such.
Under 65, buying your own coverage
PennieThis is the main case the marketplace was built for. Start a Pennie application and it will tell you what help you qualify for.
Turning 65 within the next year
MedicareYour seven-month window opens three months before your birthday month. If you are on a Pennie plan now, sort out the switch before it closes.
Under 65, on Social Security disability for 24 months
MedicareMedicare is not only about age. Enrollment is usually automatic at the 25th month.
Offered coverage at work
Usually your employer's planIf the offer counts as affordable under the law, premium help is generally off the table, which usually makes the work plan cheaper even when it is unremarkable.
Low income, or you have children
Medical Assistance or CHIPPennsylvania's Medicaid program and CHIP take applications all year. A Pennie application screens you for both automatically.
Between jobs, or you just lost coverage
Pennie, on the clockLosing coverage opens a special enrollment period, generally 60 days from the day it ends. That clock runs whether or not you have decided anything.
Fact-check us
Every claim above, sourced
None of this is our opinion about how the program works. It is what the agencies that run it publish. If this page and one of these disagree, believe them.
Official sources
- HealthCare.gov: pre-existing conditions protections (opens in a new tab)U.S. Department of Health & Human Services
- HealthCare.gov: what marketplace plans cover (opens in a new tab)U.S. Department of Health & Human Services
- HealthCare.gov: preventive care benefits (opens in a new tab)U.S. Department of Health & Human Services
- HealthCare.gov: plan categories (Bronze, Silver, Gold, Platinum) (opens in a new tab)U.S. Department of Health & Human Services
- HealthCare.gov: premium tax credit (opens in a new tab)U.S. Department of Health & Human Services
- HealthCare.gov: cost-sharing reduction (opens in a new tab)U.S. Department of Health & Human Services
- IRS: the premium tax credit, the basics (opens in a new tab)Internal Revenue Service
Additional resources
We are a broker, and a broker earns a commission when you enroll. These organizations do not, and every one of them will help you for nothing.
- PA MEDI: free, unbiased Medicare counseling from the Commonwealth (opens in a new tab)Pennsylvania's own Medicare counselors. Free one-to-one help by phone or in person, and they sell nothing.Pennsylvania Department of Aging
- 1-800-MEDICARE (1-800-633-4227): the federal Medicare help line (opens in a new tab)Medicare's own line, open 24 hours a day, for questions about your coverage, your card, or a claim.Centers for Medicare & Medicaid Services
- Find your State Health Insurance Assistance Program (opens in a new tab)The national directory of state counseling programs. Use it if you are helping someone outside Pennsylvania.SHIP National Technical Assistance Center
- Pennsylvania Insurance Department: consumer help and complaints (opens in a new tab)The regulator. Check a producer's licence, ask a coverage question, or file a complaint against an insurer or a broker.Commonwealth of Pennsylvania