ACA plan for 26 year old: What to consider and how to choose?

Please don’t make this political.

My daughter has to choose an ACA plan by the end of this month. She knows nothing about insurance and I want to help her where I can. What should I advise her to consider? What should she be careful about?

She is very healthy. She does do a an online therapy session 2x/month and would like to continue with her current provider. She needs a non-elective outpatient surgery this summer and would like to stick with the specialist she’s seen for that minor problem. She is not currently on any medications.

At first I told her to be looking at silver plans, but now, after having looked at all the well care type services that must be covered pre-deductible I am not sure. She is self employed and makes about $50K/year. In case this has anything to do with options she should consider: There is a very good chance that she will be hired in a half time or more government position with health benefits by the end of the year.

Thanks for whatever wisdom you can share.

I’d go with the highest level plan available in her area.

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I don’t know about the individual plans on the ACA, but in general high deductible plans are good for those with little to no medical costs, or have really high medical costs. Young people tend to do well there except that prescriptions count toward the deductible, so you pay 100% of the drug cost until you hit the $3000-6000 deductible. And young people might not have the money saved to pay the deductible up front.

Since she is planning to have surgery and does have therapy sessions, I would advise her not to go with the high deductible especially since she may be switching to a different one later. It would stink to pay $3000+ and then have to start over with another plan.

As far as being covered by her current provider, you’d probably be best to ask them what they take on the ACA.


Not sure what state she is in. In our state, Massachusetts, you can go to any hospital financial counseling office (during COVID you could to this by phone) and they will help you choose a plan AND enroll you on the spot.

In California there are similar services at community health centers and insurance offices.

I think she should sit down with someone with some expertise in her state.

Not looking forward to this issue when my kid with type 1 diabetes (the most hated illness by insurance companies) and other health issues graduates next year!


If there’s a chance she’ll be getting surgery before getting the gov job benefit plan, I’d suggest a PPO over an HMO. That way, she can choose the surgeon she wants to go to instead of being referred to whoever her primary care doc, or the HMO, chooses. PPOs still have networks, but there are a lot more choices for her.

As stated above, she might want to consider a high deductible plan. This is what we have, with the $3000 deductible, $6000 out of pocket plan. My husband had surgery last year, and we ended up paying roughly $5000 out of pocket (20% after hitting $3000, then up to $6000 total).

High deductible plans usually come with an HSA account that you can contribute a certain amount to each year. This year it’s $3600 for individuals. That money is contributed before taxes to be used for medical expenses. It can also transfer with you to other jobs, so you don’t lose anything that you put into it. There are also investment plans for HSAs, so someone your daughters age isn’t just allowing those funds to sit stagnant. She can earn more money on it to have more available later on.

I hate sorting through all things insurance. What a headache! Good luck to your daughter!


See if there is an insurance broker in your area. They are generally free and can help her sort out what her needs will be.

Also, she should contact her current physicians billing staffs and ask them how they work with the ACA and what they accept.


If she wants to keep her current providers and the cost of their services would be expensive out-of-network, then checking whether the current providers are in-network for any of the possible plans would be a place to start. (But also beware of the out-of-network anesthesiologist or other providers brought in without your choice or consent to a surgery at an in-network facility.)

Beyond the in-network versus out-of-network issues, the different levels of plans are basically lower premium higher deductible to higher premium lower deductible. Which costs less depends on the specific situation. Some plans may allow for an HSA as well (basically like a traditional IRA, except tax-and-penalty free withdrawals any time for qualified medical care costs, but taxed otherwise, with 20% penalty before age 65).

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Is it still the case that only certain ACA plan levels are eligible for the premium subsidy? That could be a considerable savings but then she would probably lose choice of providers.

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She can check out the projected yearly cost, out of pocket maximum, deductible and office visit costs for each plan available to her here: Health insurance plans & prices | There are a lot of filters, so she can check that her specialist is in network.

I would recommend a PPO plan.

PPO Plans cost more in my experience. But yes more choices.

Again, this is complicated, and I would sit down with someone whose job it is to advise. Every state has resources, whether at the hospital, community center, insurance agent, or something else.

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If she wants to stay with her current therapist, and the current specialist, then she has to choose a plan that they accept, or pay out of pocket. She should look into the cost of that surgery. If it requires an anesthesiologist, that’s usually a thousand bucks right there, before adding the facility fee and surgeon fee and meds and materials.

PPO plans are much more flexible than HMO plans, but often, they won’t cover out of state care, or out of network care.

When you add together annual premium plus deductible, the Platinum/Gold/Silver/Bronze total up to be the same. It’s just how you want the pie divided up. So the question is whether you want to pay a high premium and a low deductible, or a low premium and a high deductible. If as a single person she makes 50K/yr, she may not qualify for any subsidy. This is very important, since if she does qualify for a subsidy, it makes sense to choose a higher premium plan with a lower deductible.

She will likely only be on the plan for less than 6 months. So if she chooses a high deductible plan, she would have a lower premium (but only for 6 months), but be at risk for a high deductible payment. The fewer months she’s on it this year, the more bang for her premium buck she gets, because she can have a low deductible, with only a few months of a high monthly premium.

Welcome to the fun world of the self-employed, and the “Affordable” Care Act plans - which are most definitely NOT affordable!

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If one uses an insurance broker, especially for ACA plans, please make sure you find someone with experience with the Marketplace plans. I can not tell you how many of our patients will not understand that have to pay that high deductible before the insurance kicks in. Often I will hear that the agent told them they were getting the Cadillac plan, or the best plan out there, and why do they have to pay so much for their appointment when they pay a lot for their insurance? It kills me to have to tell a patient that they owe $1,000 for allergy testing, and more than that much for serum and allergy injections as they have over a $5,000 deductible.


I have a ACA plan as does one of my kids. Until two years ago I went with the bronze PPO. The lowest premium but highest deductible. I made that decision since I have the resources to pay a large deductible but I was not a big healthcare consumer. Two years ago I had a problem with my knee and knew I needed an MRI and surgery so I switched to silver. Since your daughter anticipates needed medical care silver might be best. As others mentioned she should check with the Dr and see who they are a provider for. Also if she qualifies for a subsidy I’ve heard that silver is the best value.
Also insurance agents would be no charge for your D. My agent puts together a proposal each year with the available plans and the costs. It’s free to me.

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In my state we would not go to an insurance agent, just to be clear on that. We go to the hospital financial counseling office. In California, the state has apparently trained certain insurance agents to serve the same function as the MA hospital counselors.

And you do not have to be in financial need to use the financial counseling offices here. Most people I know go there for advice.

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Thank you for the replies and advice everyone.

We are in Washington state, so we can use our state’s marketplace to filter for A 4+ star quality rating and her current providers. (Because we are also healthy, DH and I currently have a high deductible plan with an HSA, so we know how that works. We are huge fans of HSA plans for healthy folks)

When I look at only the 4 star or higher plans, the only options are Kaiser (HMO) and Premera Blue Cross (EPO).

Coverage details on Kaiser options:
Bronze : $213/month; $6000 deductible; Out of Pocket Max: $8550; Outpatient Surgery: Full price until deductible, then 40%; therapy visit $50

Kaiser Gold HMO: $326/month; $500 deductible; Out of Pocket Max: $5250; Outpatient Surgery: Full Price Before Deductible, then $75; therapy visit: $15

I will definitely encourage her to get some professional advice before she commits, but am I right in thinking for this year, the Gold plan would be a no brainer (assuming she gets confirmation both of her providers are covered)? If she ends up needing to get her own insurance next year, then she could switch to a Bronze or an HSA plan.

The Premera Gold plan is another $800 for 6 months (a no brainer for me) I will encourage her to seriously consider that option, but I’m pretty sure she won’t be interested (again, as long as her current providers are in network).

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Are the providers she wants to continue using in Kaiser or not in Kaiser?

You’re lucky to have that Kaiser HMO Gold option in your state. I think that considering it’s probably only for 6 months, and she’s possibly going to be employed by end of year, and at least has the option of changing her plan for Jan 1, that the Kaiser HMO Gold is the way to go.

According to the filter, her therapist is. I dont know the names of her specialist and surgeon, so I did not filter for that, but will show her how when I see her tomorrow.

With Kaiser I’m pretty sure you have to use the Kaiser providers. One of my kids has Kaiser through a group plan and it works well since she has had some high cost medical procedures and medications. One issue though is she is not able to see a specialist outside of Kaiser.

Typically (as in, outside of emergency care), Kaiser plans cover only use of Kaiser providers, and Kaiser providers are only accessible to those with Kaiser plans, although there may be a small number of outside providers contracted by Kaiser plans where there are not enough such providers within Kaiser.

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