Individual Health Insurance - Making an Informed Decision
Beginning in 2014, we transitioned into a new era of healthcare and individual health insurance with the advent of the Affordable Care Act (ACA). If you need health insurance because you aren’t covered through your job or your spouse’s plan, or you’ve retired but are younger than 65 and not yet eligible for Medicare, you may want to consider signing up for an individual plan under the Affordable Care Act. Our goal is to inform you of your options regarding the Affordable Care Act and help you navigate the process of obtaining coverage and determining eligibility for premium tax credits when purchasing an ACA-compliant plan.
ACA-compliant plans are plans that meet certain “Essential Health Benefit” requirements. Three significant mandates included in compliant plans are maternity care, coverage for mental health benefits, and coverage for pre-existing health conditions. There are only 4 factors used to rate policies in ACA-compliant plans:
- Family matrix
- Age
- Smoking
- Geographic area
Coverage can be obtained through any carrier that offers ACA-compliant plans, but there is a limited open enrollment period in which to apply for coverage. Open enrollment is from November 1, 2025, to December 15, 2025, for coverage effective January 1, 2026. Sign up December 16, 2025 – January 15, 2026, for coverage effective February 1, 2026. Outside the open enrollment period, you may enroll for coverage only if you have a qualifying life event and are eligible for a Special Enrollment Period (SEP).
- You move to a new area that offers different plans or isn't covered by your HMO network.
- You get married.
- You have or adopt a child.
- You lose other health coverage due to job loss, a decrease in work hours, the end of COBRA coverage, or other reasons.
- You become a U.S. citizen.
- Your income changes or some other event changes your income or household status.
- You can prove that your health insurance company violated its contract with you.
- You are no longer covered on a family member's policy because you turned 26, you have legally separated from or divorced your spouse, or the policyholder has passed away.
- You become a member of an American Indian and Alaska Native tribe.
All ACA-compliant plans are available through private health insurance companies. If you qualify for a premium tax credit, you will need to apply through the Health Insurance Exchange available through our website. The health insurance exchange, otherwise known as the Health Insurance Marketplace, is a comparison-shopping site for health insurance. Private health insurance companies list their health plans with the Exchange, and you can compare and shop from among the available health plan listings. Plans on the Exchange fall within the following categories to make it easier for consumers to compare plan premiums and coverage options: Catastrophic, Bronze, Silver, Gold, and Platinum plans. When applying through the Exchange, your premium will be calculated based on the amount of tax credit you are eligible for.
If you do not qualify for a premium tax credit, you can go to www.statewidehealthinsurance.com and easily obtain and compare current rates from carriers offering coverage in your county.
ON-EXCHANGE: You are registering to obtain the premium tax credit. You can get this as an advance to assist with paying your monthly premiums, or you can receive a lump sum credit when you file your tax return.
OFF-EXCHANGE: You are going straight to the carrier and not registering through the Exchange.
Things to know:
Individual health plans utilize separate provider networks from group plans! The key to selecting an individual plan is verifying that the providers you want to see are participating providers within that carrier’s individual network.
Individual plan options are HMO / EPO plans. There are NO out-of-network benefits.
Blue Cross Blue Shield of Texas, along with Community Health Choice, currently has the most favorable participating provider networks. Additional carrier options include: AmBetter
United
Oscar
Note: Aetna/CVS, Molina, and Friday Health are not offering ACA plans in Texas in 2026
Keep in mind that the government is not in the health insurance business! They are in the “helping you pay your premium business” if you qualify for tax credits based on your income and family size. If you register through the Exchange, your coverage is still provided through one of the private carriers that participate in the Exchange. Plan designs are the same on or off the Exchange.
The APTC or Subsidies are based on eligibility, your family size, and projected Modified Adjusted Gross Income (MAGI) for 2026. Qualifying for subsidies can lower your net premiums on an ACA-compliant health plan purchased through the Health Insurance Marketplace. For most applicants, this will be your Adjusted Gross Income reflected on Line 11 on Form 1040.
ACA Income Limits for 2026 Tax Credit Subsidies
| Family Size | Lowest eligible income** 100% FPL |
CSR Tier 1 limit 150% FPL |
CSR Tier 2 limit 200% FPL |
Highest eligible limit 400% FPL |
|---|---|---|---|---|
| 1 | $15,650 | $23,475 | $31,300 | $62,600 |
| 2 | $21,150 | $31,725 | $42,300 | $84,600 |
| 3 | $26,650 | $39,975 | $53,300 | $106,600 |
| 4 | $32,150 | $48,225 | $64,300 | $128,600 |
| 5 | $37,650 | $56,475 | $75,300 | $150,600 |
*APTC Tax Credit Subsidy Maximum Income Limit
*Determined by family members and age(s)
*APTC tax credit subsidies are based on your projected income for 2026. You can use last year’s tax return to calculate your projected Advanced Premium Tax Credit.
** Lowest eligible income: If you make less than the minimum income, you are not eligible for the Advance Premium Tax Credit and should apply for Medicaid.
The limits listed above are based on current legislative standards as of November 2025. As of the writing of this update, our legislators have not extended the enhanced limits and removed the subsidy cliff included in the American Rescue Plan Act (ARPA) that was extended through 2025.
Note: Typically, if you have employer-sponsored coverage, you are not eligible for the Advanced Premium Tax Credit unless your premium contributions exceed 9.96% of your Modified AGI.
We can assist with reviewing carrier and plan options available, both on and off the Exchange. There is no cost to the applicant when working with an agent!
A licensed health insurance agent can assist you with making an informed decision and guide you through the application process. For more information, visit our website (www.statewidehealthinsurance.com) or call us at (281) 485-0088.