Health Insurance

Health insurance in 2026 isn’t one product — it’s three. Whether you should be in the Federal Marketplace (ACA), the Private Market (Short-Term Medical or Fixed Benefit), or some combination depends on three things: your income, your health, and how much you’re willing to bet on staying healthy.

This page walks through each lane in plain English so you can figure out which one fits you. If you’d rather skip it and just talk: Book a 30-min Healthcare Review.

Quick decision guide

If you…	Look at first
Have any pre-existing condition, chronic illness, or regular prescriptions	ACA Marketplace — only one required to cover them
Are healthy, self-employed, and income is over $62,600 single / $128,600 family	STM (Short-Term Medical) — much cheaper, major medical
Have low-to-middle income and could benefit from a subsidy	ACA Marketplace — subsidy makes it competitive
Need coverage for a specific window (between jobs, bridge to Medicare)	STM is purpose-built for this
Live in a state where STM isn’t available, and ACA is either too expensive or you don’t qualify for a Special Enrollment Period	Fixed Benefit / Indemnity — can serve as a primary coverage solution on robust plans
Live in CA, NM, or WA	ACA only — STM is banned in those states

Option 1: Federal Marketplace (ACA)

The ACA Marketplace is the federal/state exchange system. The big advantage: it must cover you regardless of pre-existing conditions, and you may qualify for premium subsidies based on income.

Best for: anyone with health conditions, prescriptions, or ongoing care needs. Anyone whose income falls between 100%–400% of the Federal Poverty Level. Families looking for guaranteed-issue coverage.

2026 reality check: the enhanced premium tax credits from 2021–2025 expired. The “subsidy cliff” at 400% FPL is back. People above that line pay full unsubsidized premium. Open Enrollment for plan year 2027 runs November 1 – December 15, 2026 (shorter than prior years). Full FPL tables and subsidy zones live on our Federal Marketplace page.

How we help: Run real plan comparisons through HealthSherpa with your agent attribution intact, walk through doctor network checks, prescription formulary checks, and the subsidy math. You can self-enroll OR have us do it with you on a screen-share.

Direct path: Shop ACA plans on HealthSherpa →

Option 2: Private Market — Short-Term Medical (STM)

STM is major medical insurance — full hospitalization, surgery, ER, and outpatient coverage in one policy. It works across a wide range of situations: as a permanent solution for healthy individuals and families who don’t qualify for ACA subsidies, as bridge coverage between jobs or before Medicare, as a stopgap when you need something fast and affordable, or as a cost-effective alternative when an ACA plan’s premium just doesn’t make math sense for your situation.

The misconception worth correcting: STM is often labeled as only temporary or only gap-coverage. For many of our clients above the subsidy line, it’s the best long-term option they have — they renew it year after year and save thousands compared to unsubsidized ACA. The “short-term” label is regulatory, not strategic.

Best for: healthy individuals and families with household income above ~$62,600 single / $128,600 family of 4 (where ACA subsidies aren’t available). Self-employed, 1099, freelancers. People between jobs. People bridging to Medicare. Snowbirds with non-standard coverage needs.

What makes STM different from ACA

• Underwritten — the carrier asks health questions. Healthy people pay less.
• No subsidy — but premiums are typically 40–60% less than unsubsidized ACA plans for the same person.
• Not required to cover pre-existing conditions during the policy term. That is the trade.
• Flexible deductibles — pick $2,500, $5,000, $7,500, $10,000, $12,500, or higher (up to $25,000 with some carriers) based on risk tolerance.
• Customizable benefit structure — many STM plans let you add or remove riders (Rx, accident, preventive care) to fit your situation and budget, vs ACA’s mandatory Essential Health Benefits package.

Where 3-year STM plans are available

Several states allow 3-year STM plans (12-month initial term, renewable up to 36 months total). These are the strongest STM markets in the country because they let you stay on the same policy long enough to plan around it. Most other states cap STM at 4, 6, or 12 months without renewal. We carry STM in every state where it’s legally available — ask us about the specifics for your state.

Carriers we work with for STM

• UnitedHealthcare
• Pivot Health
• Allstate Health Solutions
• Plus several others depending on your state — ask us about specific options.

Other states’ STM caps (in our 36-state footprint)

• 12 months renewable to 36 months (federal default): AL, AR, AZ, DE, GA, IA, ID, IN, KY, LA, MN, MO, MS, MT, NE, NH, OH, PA, SC, SD, TN, UT, WV
• 6 months max: CT, IL, NC, TX, VA
• 3 months max: MD, OR, VT
• NOT available: California, New Mexico, Washington (state-banned)

The honest trade-off (we don’t sugarcoat)

• If you stay healthy: STM is dramatically cheaper.
• If you get diagnosed mid-policy: current STM covers it through the policy term. At renewal, the new policy can exclude that condition or decline you entirely.
• Your fallback is always ACA — they can’t decline you for any pre-existing condition during Open Enrollment.

The smart play: STM while healthy + ACA as your safety net if your health changes.

Direct path: Book a Healthcare Review — STM has real pitfalls if you pick the wrong plan, so we walk through it together before you enroll.

Option 3: Private Market — Fixed Benefit / Indemnity

Fixed Benefit (also called Hospital Indemnity) plans pay a set benefit amount when specific medical events happen — a hospital admission, a surgery, an ICU stay, an emergency room visit. On robust plans, the benefit is paid directly to the provider when in-network; out-of-network, you can submit the bill and get reimbursed up to the stated amount.

For clients in the right situation, a robust Fixed Benefit plan can serve as a primary coverage solution — particularly when STM isn’t legally available and an unsubsidized ACA plan is unaffordable.

Best for

• People in the 3 STM-banned states (CA, NM, WA) who need a Private Market alternative
• People who already have ACA or employer coverage and want to backfill high deductibles
• Healthy people who want low-cost “what if” protection — lighter-tier plans often skip the long medical questionnaire (robust plans do underwrite, similar to STM)
• People in states where longer STM plans (12-month or ideally 3-year) aren’t available, and the Federal Marketplace is either too expensive or unavailable because they don’t have a Special Enrollment Period (SEP) trigger

What it covers (typical)

• Daily hospital admission: typically $2,000–$5,000/day on average — can be as low as $1,000 (or less) on lighter plans, or higher on more robust ones
• ICU stays: roughly double the daily hospital benefit on most plans
• Surgery: benefit varies widely by plan and carrier. UnitedHealthcare‘s Premier plan, for example, pays up to $50,000 for the primary surgical benefit and adds separate payouts for anesthesia, assistant surgeon, and other components. Other carriers like Manhattan Life use different payout structures that can exceed $50,000 in certain scenarios. Lighter plans pay significantly less
• Outpatient ER: $250 to several thousand per visit, depending on plan tier
• Some plans include diagnostic imaging, ambulance, and prescription riders
• Doctor visits, diagnostic testing, and wellness — robust Fixed Benefit plans cover routine office visits, labs, imaging, and preventive care, often with flat per-visit benefit amounts
• True PPO-style behavior on robust plans. Most of the stronger Fixed Benefit / Indemnity plans (the ones that function like real health coverage) pay the provider directly when in-network. If your provider is out of network, you can submit the bill and get reimbursed up to the stated benefit amount — so you keep flexibility without losing the cash mechanic.

What it does NOT do

• Cover pre-existing conditions (usually 12-month waiting period).

Carriers we work with for Fixed Benefit

• UnitedHealthcare
• Allstate Health Solutions
• Manhattan Life
• Plus several others depending on your state — ask us about specific options.

Best use case (real talk)

Pair a Fixed Benefit plan with a high-deductible ACA Bronze plan. The ACA handles catastrophic + pre-existing protection; the Fixed Benefit gives you cash to cover your deductible if you get hospitalized. Often costs less than mid-tier ACA and gives broader functional protection.

Child-only plans

Need coverage for just a minor (under 18) standalone? Most Private Market carriers won’t write child-only policies. The two we work with that do:

• Pivot Health — STM child-only plans
• Allstate Health Solutions — Fixed Benefit child-only

A parent or guardian needs to be on the call for enrollment.

Option 4: Travel Medical Insurance

Your regular U.S. health coverage — ACA plan, STM, employer plan, Medicare — almost never covers you outside the country. That’s a real problem if you’re leaving the U.S. for anything more than a long weekend. Travel medical insurance fills that gap: hospital admission, emergency treatment, and medical evacuation home if things go really wrong.

When you need this:

• You’re traveling internationally for more than a few days
• You’re an expat, retiree, or nomad living abroad long-term
• You’re on Medicare — Original Medicare has essentially zero foreign coverage, and Medicare Advantage usually caps at emergency-only
• You’re doing missionary, humanitarian, or business work overseas
• You’re an adventure traveler (skiing, climbing, diving) — most standard travel plans exclude these, but specific plans cover them

Our carrier lineup:

International Medical Group (IMG) is our preferred travel medical carrier — 30+ years in the space, with everything from single-trip Patriot plans to multi-trip annual coverage to adventure/sport-specific plans. When IMG isn’t the right fit — whether it’s the coverage tier, the price point, or a specific travel scenario — we also write with WorldTrips.

The honest trade-off: travel medical has real variety — single trip vs. annual multi-trip, standard vs. adventure, primary vs. secondary coverage. The right plan depends on how long you’re gone, where you’re going, and what you’re doing while you’re there. We’d rather walk through it with you before you enroll than risk you buying the wrong thing.

Direct path: Quote & enroll with IMG (if you know what you need) — or Book a Healthcare Review so we can match the trip to the right plan.

What people usually get wrong

After hundreds of Healthcare Reviews, here are the mistakes we see most:

• Picking Bronze on the ACA when you qualify for CSR on Silver. If your income is under 250% of FPL, Silver gives you Cost-Sharing Reductions that lower your deductibles and out-of-pocket max — sometimes by thousands. Bronze gives you the premium subsidy but NOT the CSR.
• Assuming STM is just a “stopgap.” For healthy people above the ACA subsidy line, STM is often the best long-term solution. Three-year FL plans make this even truer.
• Falling into the Medicaid gap. If your household income is under 100% FPL in a non-expansion state, you make too little for ACA subsidies AND too little for state Medicaid as a childless adult. Private Market is your answer.
• Buying duplicate coverage. Sometimes people have employer coverage AND ACA AND a Fixed Benefit plan. Often two of those are wasted money. We audit your current coverage before recommending anything new.
• Picking based on premium alone, ignoring network. A cheap plan whose network excludes your doctor isn’t cheap — it’s expensive. We always run a doctor + prescription network check.
• Not updating income with the Marketplace mid-year. If you get a raise or lose a job, update the Marketplace immediately. Otherwise you might owe subsidy clawback at tax time or miss savings during the year.

Book a 30-min Healthcare Review →

Or use the DIY (our AI guide, Lulu) to ask questions on your own time: Open the DIY tool.