What Marketplace Health Plans Cover, and What They Usually Do Not

The ten essential health benefits

Under the Affordable Care Act, every Marketplace plan has to cover ten categories of care, known as essential health benefits:

1. Outpatient care, such as doctor visits and outpatient procedures.
2. Emergency services.
3. Hospital care, including surgery and overnight stays.
4. Pregnancy, maternity and newborn care, before and after birth.
5. Mental health and substance use disorder services, including counseling and behavioral health treatment.
6. Prescription drugs.
7. Rehabilitative and habilitative services and devices, such as physical therapy after an injury, or therapy that helps someone with a disability or chronic condition gain or keep skills.
8. Laboratory services.
9. Preventive and wellness services and chronic disease management.
10. Pediatric services, including dental and vision care for children.

Each state chooses a benchmark plan that fills in the details within those categories, so the exact list of covered services varies somewhat by state. Within a state, plans still differ on cost-sharing, drug lists and networks. Mental health and substance use care also has to be covered on terms comparable to medical care.

No annual or lifetime dollar limits

Marketplace plans cannot put an annual or lifetime dollar cap on essential health benefits. Instead, you get an out-of-pocket maximum. Once your deductible, copays and coinsurance for covered in-network care reach that number in a year, the plan pays 100 percent of covered in-network care for the rest of the year. For 2027 the maximum can be as high as $12,000 for one person and $24,000 for a family, and many plans set it lower. Your premium does not count toward it.

Preventive care with no cost share

A long list of preventive services is covered with no copay, coinsurance or deductible when you use an in-network provider. That includes things like an annual checkup, blood pressure and cholesterol screening, many cancer screenings, recommended vaccines, well-child visits and, for women, well-woman visits and contraception, with some exceptions. The list is based on federal recommendations, and HealthCare.gov publishes it.

Two caveats. If the visit also deals with a new problem or an ongoing condition, part of it can be billed as regular care, with your normal cost-sharing. And the no-cost rule applies in network; preventive care out of network may cost you, or not be covered at all.

Pre-existing conditions

A Marketplace plan cannot turn you down, charge you more or refuse to cover treatment because of a health condition you had before coverage started. That includes conditions such as diabetes, asthma, a cancer history or a current pregnancy. Coverage for the condition starts on the plan's first day, with no waiting period. Prices can vary only by age, location, tobacco use and whether the plan covers one person or a family.

That guarantee is the main thing the Marketplace offers that private, medically underwritten plans do not. On a private plan, approval depends on your health answers and benefits vary by plan. The pre-existing conditions guide explains how that side works.

Metal tiers

Plans are grouped by how they split costs with you, not by the quality of care. Each tier is designed to pay roughly a set share of average costs:

• Bronze, about 60 percent. The lowest premiums and the highest costs when you use care. Starting in 2026, bronze plans count as HSA-eligible; the HSA guide explains how that works.
• Silver, about 70 percent. The benchmark used to calculate the tax credit.
• Gold, about 80 percent. Higher premiums and lower costs when you use care.
• Platinum, about 90 percent, where insurers offer it.

There are also catastrophic plans for people under 30 and some people with a hardship exemption. They have very high deductibles and do not qualify for the tax credit.

With one insurer, the doctors, hospitals and drug list are often the same at every tier. What changes is the trade between the monthly premium and what you pay when you get care. The guide to reading a quote breaks down deductibles, coinsurance and out-of-pocket maximums.

Networks: the part people miss

Covered does not mean covered anywhere. Marketplace plans come in a few network types:

• HMO. You use the plan's network and usually need a referral to see a specialist. No out-of-network coverage except emergencies.
• EPO. You stay in the network, usually without referrals. No out-of-network coverage except emergencies.
• PPO. In-network and out-of-network benefits, with out-of-network care costing more.
• POS. A mix, often with referrals and some out-of-network benefits.

In Florida, many Marketplace plans are HMOs or EPOs built around a local hospital system. That can be good value if your doctors are in it. It can be a problem if you travel, split time between states, or want a particular specialist or hospital. Check every doctor, hospital and prescription in the plan's own directory before you enroll, rather than going by the insurer's name.

Emergencies are the exception. Emergency care is covered out of network at in-network cost-sharing, and federal surprise billing rules protect you from most balance bills for emergency care.

What Marketplace plans usually do not cover

The essential benefits are a floor, not everything. Common gaps:

• Adult dental and vision. Children's dental and vision are part of the benefits, but adult dental care, glasses and contacts usually are not. Standalone dental plans are sold separately, including on the Marketplace.
• Long-term care, such as custodial care in a nursing home.
• Cosmetic procedures that are not medically necessary.
• Some medications. Each plan has its own drug list. A drug you take may be covered on one plan and not another, or require prior authorization. Coverage for weight-loss medications in particular varies by plan.
• Out-of-network care on HMO and EPO plans, outside emergencies.
• Most care outside the United States.
• Services that vary by state, such as fertility treatment, adult hearing aids and weight-loss surgery.

Comparing two plans with the same coverage list

Because every plan covers the same categories, the real differences are in the details:

1. Are your doctors, hospital and pharmacy in the network?
2. Are your prescriptions on the drug list, and at what tier?
3. What is the deductible, and which services are covered before you meet it?
4. What is the out-of-pocket maximum?
5. Do you need referrals to see specialists?
6. What is the premium after your tax credit, if you get one?

Every plan has to provide a Summary of Benefits and Coverage, a standard document that answers most of these in the same format, so you can compare plans side by side.

If you earn too much for a credit

For 2027 there is no tax credit above 400 percent of the federal poverty level, which is $63,840 for one person or $132,000 for a family of four. You can still buy any Marketplace plan at full price, and for anyone with an ongoing condition that guarantee is worth paying for. For healthy households over the line, a private plan priced on health instead of income is worth comparing. Approval depends on your health answers and benefits vary by plan. The no-subsidy guide walks through that comparison.

Where I fit

I am an independent broker licensed in 31 states. I can show you Marketplace plans with your real tax credit, check your doctors and prescriptions against each one, and put private options next to them when they make sense. There is no fee to you. Start a quote or call (786) 218-2384. Open enrollment for 2027 coverage runs November 1, 2026 through January 15, 2027; the open enrollment guide has the dates that matter.