How Delawareans can navigate the ACA marketplace

With only a few weeks left to enroll in an Affordable Care Act health insurance plan, here is what Delawareans need to know about the annual enrollment period and some of the state resources available to them.

The annual enrollment period, better known as "open enrollment," opened on Nov. 1, and will close on Dec. 15, for those looking to receive coverage that starts on the first day of 2026. The last day to sign up for coverage for the 2026 plan year is Jan. 15, 2026.

Open enrollment offers the ability to purchase plans for people who do not receive it through an employer or federal subsidy like Medicare or Medicaid. Those trying to enroll should use the federal government's official website to avoid any websites offering illegitimate plans.

Understanding the terms within health plans

When it comes to making decisions about health care coverage, understanding the language within those plans can allow patients to make better-informed choices. According to the Delaware Department of Insurance's "Smart Buyer's Guide," here are some of the key terms enrollees should understand.

Premium: The payments that enrollees make monthly to have access to their insurance plans.

Deductible: The amount of money a patient would pay up front for a service before their insurance pays.

Copayment: A charge that patients pay for prescriptions and doctor's visits on top of their deductible.

Coinsurance: The percentage of a procedure that patients pay for after a deductible. This would mean if a patient has a 40% coinsurance and paid their deductible, they would still pay that amount and insurance would pay the other 60% of a procedure.

Out-of-pocket maximum: The maximum amount of money a person pays each year before insurance begins to cover 100% of costs.

For any other terms or programs buyers may have questions about, the federal government offers a glossary of terms relevant to plans.

What type of plans can I get?

Plans on the open market are broken into four tiers: Bronze, Silver, Gold and Platinum. Coverage under those plans can differ, as well as the private providers who offer them.

Bronze plans, while offering some of the lowest monthly payments, often have higher deductibles and weaker coverage overall.

Silver plans offer a balance between the lower prices of a bronze plan and enhanced coverage of higher tier plans. Silver plans also offer lower deductibles than their Bronze counterparts, as well as have lower out-of-pocket maximums.

Gold plans are the first tier where monthly premiums are noticeably higher than lower options, but with lower, if any, deductibles. They are also the first tier to include adult and child dental coverage options.

Lastly, Platinum options offer the highest monthly premiums with some of the lowest deductibles, out-of-pocket maximums and access to coverage.

According to the glossary, there are also different types of plans within the tiered-system that offer varying benefits: Preferred Provider Organization (PPO), Health Maintenance Organization (HMO) and Exclusive Provider Organization (EPO) plans.

PPO plans contract with medical providers and specialists to create a network for patients, with enrollees paying less if they stay in the network. Patients also are able to use their insurance out of network, but it may cost more.

HMO plans are a bit more restrictive, requiring that patients stay and possibly live within a provider's network. EPO plans are similar to HMOs, only offering services if patients stay within the provider's network of hospitals and specialists, barring emergencies.

Why are plan prices much higher?

Affordable Care Act premiums are likely to increase by 26% next year, according to KFF, a health research organization. This does not include price hikes for those who are eligible for plans subsidized by enhanced tax credits, which were at the center of last month's federal government shutdown.

That spike is projected to raise costs by an average of 114%, according to KFF.

Congress first enhanced those tax credits – which essentially subsidize monthly bills for enrollees in the health insurance marketplace – during the COVID pandemic, but that increase is set to expire at the end of this year.

During the shutdown, Spotlight Delaware examined how three hypothetical families might be impacted if those tax credits expire at the end of the year. Democrats ultimately conceded on their efforts, voting to reopen the government without an extension to the tax credits.

In one of these hypotheticals, a 64-year-old single woman living in Seaford making $57,000 a year may pay $459.50 a month for a standard silver marketplace plan – $90 more than 2025.

But if those credits lapse, she would pay $1,608.50 a month.

Another hypothetical family of four living in Newark with an annual household income of $110,000 would see their monthly premiums on a silver plan jump from $609.05 with the credits to $2,322.15 without them.

A couple in their early 50s living in Dover and making $87,000 a year who were eligible for credits in 2025 but not in 2026 would pay $1,905.22 more a month.

Is there any available assistance?

Trinidad Navarro, Delaware's insurance commissioner, said only about 5% of the state's population will purchase health insurance through open enrollment, and that most other people are privately insured through their employer.

He said those looking to purchase plans on the open market could consider using independent health navigators with community health providers like Westside Family Healthcare or La Red Health Center.

In an interview with Spotlight Delaware, he directed residents to his office's guide to see some of the more common pitfalls with enrollment. One point he stressed about enrollment is that the government will not call residents about their insurance plans.

"If you're ever pressured to purchase anything, hang up," Navarro said. "But keep in mind that these federal agencies don't call people unless you call them first, and you'll get a call back."