How can I choose the best health insurance for me?
There are numerous factors to take into consideration when you’re shopping for health insurance
9 strategies when choosing coverage
- Check provider networks and covered drug lists
- Determine your worst-case scenario
- Make some back-of-the-envelope comparisons
- But don’t focus entirely on the cost of claims
- Consider Silver plans’ cost-sharing subsidies
- Gold plans may be a better value in some areas
- Look at Quality Ratings & check with state regulators
- Remember: one size does not fit all
- Understand your subsidy eligibility
When it comes to selecting a health insurance plan, the premium is the most important factor for many shoppers – especially those who are currently healthy. But price shouldn’t be the only factor upon which you base your selection, even if your primary concern is financial (as opposed to factors such as provider networks, drug formularies, and quality ratings).
9 strategies when choosing coverage
1. Check provider networks and covered drug lists
If you have preferred medical providers and/or take any prescription medications, those factors will likely be among the first that you should consider when you’re shopping for health coverage.
Each health plan creates its own provider network and drug formulary (covered drug list), so there’s a lot of variation from one plan to another in terms of which providers will be in-network and which drugs will be covered.
Some plans have tiered networks, which have lower copays and deductibles as long as you go to doctors and hospitals in the top tier. And even if two plans both have the same drug in their formulary, they may cover it differently (in a different tier, for example, with different out-of-pocket costs).
If you’re transitioning from an employer-sponsored health plan to the individual market, keep in mind that the provider networks and drug formularies can be very different in the two markets, even if the same health insurance company offers the plans. Don’t assume that a plan will cover your drugs and include your doctors in its network just because of the experience you’ve had with another plan from that same insurer.
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2. Determine your worst-case scenario
To determine your “worst-case scenario,” just add a plan’s total annual premiums plus the maximum out-of-pocket for each plan, and see how they stack up. If you qualify for a premium subsidy, make sure you use the after-subsidy premium for each plan when calculating how much the coverage will cost. And keep in mind that the out-of-pocket maximum is only applicable as long as you use in-network providers.
You can find the premium and maximum out-of-pocket details even before creating an account with your state’s exchange, by using the exchange’s plan browsing tool. It only takes a minute or two and doesn’t need any identifying data.
In 2027, ACA-compliant plans have a maximum out-of-pocket of no more than $12,000 for an individual or $24,000 for a family,1 although many plans have lower out-of-pocket limits. (Again, these limits only apply to in-network care. If your plan covers out-of-network care, the out-of-pocket costs for that can be much higher.)
And as has been the case since 2016, all family plans are required to have embedded individual out-of-pocket maximums.2 That means no single individual on a family plan will be required to pay more than $12,000 in out-of-pocket costs for in-network care in 2027, even if the family deductible has not yet been met.
But some plans – especially at the Gold and Platinum levels, plus Silver-level plans for people who qualify for cost-sharing reductions – have maximum out-of-pocket limits significantly lower than those amounts. And they also cover more expenses before the out-of-pocket maximum is reached. Those factors are important to consider when you’re comparing the overall cost of various plans.
3. Make some back-of-the-envelope comparisons
Let’s look at a hypothetical example for Kelly, a single 35-year-old applicant who doesn’t qualify for subsidies. She’s considering three different plans – one Bronze, one Silver, and one Gold. All of them cover preventive care at no charge, as required by the ACA.
For this comparison, we’re assuming the Gold plan is less expensive than the Silver plan, which is often the case due to the cost of cost-sharing reductions (CSR) being added to Silver plan premiums in many states.
The following plan descriptions are hypothetical and overly simplified to make the math easy. Although Bronze, Silver, and Gold plans pay an average of 60, 70, and 80% of average total healthcare costs, respectively, their plan structure varies significantly from one policy to another, even within the same metal level.
Standardized health plans are available in most states. But other than California (where all plans are standardized), non-standardized plans are also available. So it can be difficult to make an apples-to-apples comparison of plans, even within the same metal level. Some plans have separate deductibles for services like hospitalizations and prescription drugs, some have copays for office visits while others count office visits towards the deductible. There’s no way to really compare plans without reading at least some fine print. But for our back-of-the-envelope comparison, we’ll just look at deductibles, coinsurance, and maximum out-of-pocket exposure.
- The Bronze plan is $500/month, and has a $9,000 deductible with all claims applied to the deductible. After the deductible, Kelly would pay 40% of her claims until she reaches an $11,000 maximum out-of-pocket.
- The Silver plan is $700/month, has a $6,000 deductible, and Kelly will be responsible for 30% of the claim after the deductible, until she reaches a $10,000 maximum out-of-pocket (If Kelly qualifies for cost-sharing reductions, her out-of-pocket costs on a Silver plan will be lower. This is discussed in more detail below).
- The Gold plan is $600/month, has a $2,000 deductible, and Kelly will pay 20% of her claims after the deductible until she reaches the maximum out-of-pocket of $8,000.
(Note that these are just examples. In the real world, pricing and coverage vary significantly depending on the plan, the area, and the person’s age, and most people qualify for subsidies that offset some of the cost.)
We can easily calculate the worst-case scenario for the three plans: Multiply the premium by 12 months, and add it to the maximum out-of-pocket to see the total financial exposure for each plan:
- Bronze: $6,000 + $11,000 = $17,000
- Silver: $8,400 + $10,000 = $18,400
- Gold: $7,200 + $8,000 = $15,200
But for most people, large claims don’t happen very often. And although some people may not use their coverage at all during the year, most people fall somewhere in the middle. Especially if you have a pre-existing condition, you can be relatively sure that you’ll incur at least some claims during the coming year. That’s where it’s helpful to judge each plan based on how it would perform in the event of relatively minor – but still expensive – claims.
What if Kelly breaks her arm and incurs a claim that totals $7,000 after the network-negotiated discount? Here’s her total expense for the year (premiums + out-of-pocket costs) with each plan:
- Bronze: $6,000 + $7,000 (total claim applied to the deductible) = $13,000
- Silver: $8,400 + $6,000 (deductible) + $300 (30% of the remaining $1,000) = $14,700
- Gold: $7,200 + $2,000 (deductible) + $1,000 (20% of the remaining $5,000) = $10,200
If the only health insurance claims you make are for covered preventive care, a Bronze plan is going to end up being the least expensive option, because the premiums are lowest and certain preventive care is covered 100% on all plans. But if you have other claims, a plan with a higher metal level might save you money over the course of the year, even though the premiums are higher. So even if price is the most significant factor in your decision, it’s important to remember to include the cost of a claim as well as the cost of the plan itself.
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4. But don’t focus entirely on the cost of claims
On the other hand, don’t let yourself get so enamored with the low out-of-pocket expenses on the more robust plans that you inadvertently end up paying more than you need to. We often see plan comparisons where the difference in premium is greater than the difference in potential out-of-pocket savings.
For example: a plan with a deductible that is $1,000 lower than a competing plan, but that costs $100 more per month and offers similar coverage after the deductible. Buying it would mean you’d spend an extra $1,200 in premiums, to possibly save $1,000 if you have a significant claim. That’s why it’s important to spend a little time crunching numbers before you select a plan.
And if one of the plans you’re considering is HSA-qualified, don’t forget to account for the potential tax savings if you were to contribute to an HSA during the year. Assuming you’d be willing and able to contribute to an HSA, you’d want to subtract the tax savings from the total amount that each plan is going to cost you, so that you can get an accurate overall picture of how each plan would affect your finances. You may want to speak with a tax professional to understand exactly how HSA contributions would affect your overall tax burden.
Note: All Bronze and Catastrophic plans purchased in the Marketplace are HSA-eligible.
5. Consider Silver plans’ cost-sharing subsidies
Silver plans have proven to be the most popular choice in the exchanges. Even for 2026, when a significant number of enrollees downgraded to Bronze plans to mitigate some of the sticker shock that resulted from the expiration of federal subsidy enhancements, 43% of enrollees selected Silver plans, which was higher than any other metal level.3
One reason for the popularity of Silver plans is cost-sharing reductions, or CSR (also known as cost-sharing subsidies). If your household income does not exceed 250% of the federal poverty level (FPL), you’re eligible for cost-sharing subsidies in addition to premium subsidies.
During the open enrollment period for 2026 health plans, more than 23 million people enrolled in plans through the exchanges nationwide. More than 9.8 million of them selected Silver plans. And most of those Silver plan enrollees — nearly 8.6 million — enrolled in plans with built-in CSR benefits.3
For 2027 coverage, 250% of FPL is $39,900 for a single individual in the continental United States, and $82,500 for a family of four. The CSR benefits are strongest, however, for people with income that doesn’t exceed 200% of FPL, which is $31,920 for a single person, and $66,000 for a family of four. (This is all based on the 2026 poverty level numbers, which are used to determine Marketplace subsidy eligibility for 2027 coverage.)
Cost-sharing subsidies are automatically included in Silver plans for enrollees whose income makes them eligible to receive cost-sharing subsidies. Cost-sharing subsidies are not available at the other metal levels, and do not show up among the available plan selections for people with income too high for CSR eligibility. These plans have lower out-of-pocket maximums and higher actuarial value than a regular Silver plan – they’ll save you money when you need to use your health coverage. And you can apply your premium subsidy towards their purchase price.
Cost-sharing subsidies are not always as well understood as premium subsidies, but as long as applicants are actively comparing the nuts and bolts of each available plan – as opposed to just looking at premiums – the Silver plans that include cost-sharing subsidies will stand out as options that offer exceptional value. For most applicants, they will be more expensive than Bronze plans (and usually also more expensive than Gold plans), but will provide better coverage. Their out-of-pocket maximums will be lower than those of non-Silver plans, and they will also cover more medical expenses before the out-of-pocket maximum is reached.
6. Understand why Gold plans may be a better value in some areas
You might find that there are some Gold plans in your area that cost less than Silver plans. If you’re not eligible for cost-sharing reductions and there are low-priced Gold plans available in your area, these might present the best value.
Now for the how and why: Although the Trump administration eliminated funding for CSR in late 2017, CSR benefits continue to be available to eligible enrollees. The Congressional Budget Office estimated that the elimination of CSR funding would increase average Silver plan premiums by about 20% in 2018, and most insurers did add the cost of CSR to their Silver plan premiums.4
This is referred to as “Silver loading” or “premium alignment.” The latter term is used to describe the fact that Silver plans are priced higher than Gold plans because the vast majority of Silver plan enrollees get strong CSR benefits, meaning that in almost all cases, Silver plans have a higher actuarial value than Gold plans, and are priced accordingly.
Because premium subsidies are based on the cost of Silver plans, the majority of the premium increase to cover the cost of CSR is ultimately still being paid by the federal government, in the form of larger premium subsidies.
But due to the CSR funding cut, Silver plans in some areas now actually cost more than Gold plans, and some enrollees can qualify for premium-free Gold plans after their subsidy is applied. For people with income below 200% of FPL (about $31,920 for a single individual in the continental U.S. in 2027), the best choice is probably a Silver plan. This is because the out-of-pocket costs are much lower due to CSR, and premium subsidies will offset much of the higher premiums, since subsidy amounts are based on the cost of a Silver plan.
But people with income above 200% of FPL might be better off with a Gold plan instead of a Silver plan if the premiums are quite similar. (CSR is available up to 250% of FPL, but its effects are much less significant once you exceed 200% of FPL , unless you’re in a state that has its own additional CSR benefits).
Consumers should shop carefully and look at all available options before making a decision – don’t assume that pricing will follow the patterns we saw pre-2018, when premiums generally rose consistently from one metal level to the next.
Although premium subsidies offset the increased cost of Silver plans for most people, Silver plans are disproportionately expensive in most areas for people who aren’t eligible for premium subsidies. If they buy a Silver plan, they’re paying not only for the regular cost of the coverage, but also for the cost of CSR, since that cost is baked into the premiums for Silver plans in most areas.
This is a part of the reason Silver plan selections have dropped off since 2017; people who don’t get premium subsidies are generally better off with a plan at a different metal level.
7. Look at Quality Ratings and check with your state’s insurance department
After you’ve narrowed down the options based on premiums, out-of-pocket costs, how the available plans will cover your prescriptions, and which plans have your preferred medical providers in-network, you might also want to consider Quality Ratings. Many of the Marketplace plans available in your area will have star ratings under the Quality Rating System.
This is another piece of the puzzle, but for most people, it should be a way to narrow down the options after you’ve considered the other points described above, rather than a starting point.
Keep in mind that not all plans have star ratings; if a plan is too new or doesn’t have a large enrollment, it may just say that it’s not rated. That’s not a reason to avoid a plan, as it may be an excellent plan that’s simply new to the market.
You can also contact your state’s insurance department, which regulates all of the health insurers that offer Marketplace coverage in the state. In some states, the insurance department publishes overviews of the complaints they’ve received about insurers operating in the state, including ratios that make it easier to compare complaints across a market in which insurers may have very different market shares. (Michigan and Colorado are examples.) And some states provide very detailed complaint reports, including specifics of what triggered the complaints and how they were resolved. (New York is an example.)
You may find this information on your state’s insurance department website; if not, you can call them to ask whether it’s information that they can share with you.
8. Remember: one size does not fit all
If your household income doesn’t exceed 200% of FPL (this amounts to $54,640 for a family of three enrolling in 2027 coverage), a Silver plan with integrated cost-sharing subsidies will likely be the best choice for you, and will likely provide a better overall value than the Bronze, Gold, or Platinum plans.
This might also be true for people with income between 200 and 250% of FPL , but as noted above, a Gold plan might be a better value in some areas, due to the way some states and insurers are adding the cost of CSR to premiums.
People who have moderate pre-existing conditions and expect to file claims during the upcoming year will probably be better served by a higher-level plan (or a cost-sharing Silver plan if they qualify for it), regardless of premiums.
But very healthy applicants may find that they prefer the lower premiums of a Bronze plan, despite the potential for higher costs if they do need to file a claim. And enrollees with very serious medical conditions, who know they will meet their plan’s maximum out-of-pocket no matter what plan they select, might find that they’re also better off with a lower-cost Bronze plan, since the combined total cost of the premiums and out-of-pocket exposure might end up being lower.
There’s no one-size-fits-all when it comes to health coverage; each person’s health history, risk tolerance, and budget have to be taken into consideration when selecting a plan.
Personal assistance from a navigator or broker will be invaluable if you’re struggling to compare the various options available to you. (You can call one of healthinsurance.org’s partners at 888-383-5527 to talk with a licensed, exchange-certified broker who can enroll you in an ACA-compliant plan.)
9. Understand your subsidy eligibility
If you’re currently enrolled in an off-exchange plan or a non-ACA-compliant plan, you’ll want to be sure to compare all of the options that are available in your area for 2027.
The income limit to qualify for a subsidy will be higher in 2027 than it was in 2026, simply because the federal poverty level has increased. For 2026, a single person in the continental U.S. couldn’t earn more than $62,600 to qualify for a premium subsidy, but that has grown to $63,840 for 2027.5
If your income is a little too high to qualify for subsidies, contributions to a pre-tax retirement account and/or a health savings account (HSA) will reduce your income under ACA rules (note that you must have an HSA-eligible health plan in order to contribute to an HSA, but that includes all Marketplace Bronze plans).
It’s important to make sure you’re enrolled in a health insurance Marketplace/exchange plan (and the option that best fits your needs and budget) to take advantage of premium subsidies, since no subsidies are available outside the exchange.
Subsidies cannot be used with Catastrophic plans, even if they’re purchased in the Marketplace. But all other Marketplace plans can be subsidy-eligible.
Footnotes
- “Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2027 Benefit Year” Centers for Medicare & Medicaid Services. Jan. 29, 2026 ⤶
- “The Embedded Out-of-Pocket Maximum is Here for Family Group Health Insurance Coverage” HNI.com. Accessed Sept. 18, 2024 ⤶
- “2026 Marketplace Open Enrollment Period Public Use Files” CMS.gov. Accessed Oct. 8, 2026 ⤶ ⤶
- “Silver Loading (§ 156.80)” — Part of the HHS Proposed Notice of Benefit and Payment Parameters for 2026. U.S. Department of Health & Human Services. Oct. 10, 2024 ⤶
- “2025 Poverty Guidelines” and “2026 Poverty Guidelines” U.S. Department of Health & Human Services. Accessed Oct. 8, 2026 ⤶
