Health Insurance for Individuals in 2026: A Complete Guide to Costs, Networks, Deductibles, and New Rule Changes
- Nicholas Kuhl
- Nov 16
- 5 min read
Updated: Nov 18
The individual health insurance market in 2026 continues to evolve. Rates have shifted, networks are changing, out-of-pocket limits increased, and both Marketplace and private carriers introduced new rules that affect individuals shopping for coverage.
This guide is designed as a complete, plain-English walkthrough of everything individuals need to know for 2026. No jargon, no sales pressure. Just straightforward information.
By the end, you will understand:
Average individual premiums in 2026
How MAGI (Modified Adjusted Gross Income) affects your subsidy
PPO vs HMO vs EPO vs POS networks
How deductibles, copays, and coinsurance actually work
The 2026 ACA rule changes
Marketplace plans vs Private PPO plans
What plan type fits different situations
What mistakes to avoid when shopping
When to switch coverage
Where to find additional trustworthy resources
Average Individual Health Insurance Costs in 2026
Across most states, Marketplace insurers filed average premium increases between 7 and 12 percent. These increases came from rising medical claims, inflation, and renegotiated hospital contracts.
Average individual premiums for a 30-year-old, unsubsidized:
HMO plans: 470 to 580 per month
EPO plans: 500 to 640 per month
PPO plans: 650 to 780 per month
Average individual deductibles in 2026:
Bronze plans: 6300 to 9000
Silver plans: 4200 to 6000
Gold plans: 1900 to 3500
Average out-of-pocket maximums:
Minimum allowed in 2026: 9200
Maximum allowed in 2026: 9450
These numbers mean:
An individual with a major medical event may still pay around 9000 out-of-pocket before insurance covers 100 percent.
How ACA Subsidies Work in 2026
ACA subsidies are based almost entirely on your income. The key number is your MAGI.
What is MAGI?
MAGI stands for Modified Adjusted Gross Income. It is not your gross income and not your take-home pay.
MAGI = Adjusted Gross Income (AGI) + certain tax adjustments
For most people, MAGI is close to your taxable income on your 1040, with small adjustments.
Useful resource: IRS explanation of MAGI (https://www.irs.gov)
Income ranges for a single adult in 2026:
Under 21870: highest subsidy amounts
21870 to 43740: medium subsidies
43740 to about 58000: small subsidies
Above 58000: little or no subsidy
Subsidies lower your monthly premium but do not guarantee a low deductible. Many subsidized plans still have high cost-sharing.
Understanding Plan Networks in 2026
Network type determines which doctors and hospitals you can use. This is often more important than the premium.
PPO
Broadest network
Allows out-of-network benefits
No referrals required
Higher monthly cost
HMO
Most restrictive network
Requires using HMO doctors and hospitals
No out-of-network coverage
Lowest monthly premiums
EPO
Middle ground network
No referrals needed
Usually no out-of-network benefits
Becoming more common in 2026
POS
Combination of HMO and PPO rules
Less common now
Marketplace plans in 2026:
Mostly HMO or EPO networks.
PPO availability continues to shrink.
Private PPO plans:
Often include national networks such as Aetna Open Access or Cigna PPO.
Deductibles, Copays, Coinsurance and Out-of-Pocket Max Explained
Many individuals confuse these terms. Here is a simple explanation.
Deductible
The amount you pay before insurance pays for most services.
Copay
A fixed amount for specific services, such as 30 for a primary care visit.
Coinsurance
A percentage you pay after the deductible, such as 20 percent or 40 percent.
Out-of-pocket maximum
The most you will pay during the year.
Once you hit this number, the plan pays 100 percent.
Example for a 2026 individual Marketplace plan:
Monthly premium: 540
Primary care visit: 40 copay
Specialist visit: 85 copay
Deductible: 6500
Coinsurance: 40 percent
Out-of-pocket max: 9450
This means a large surgery or hospitalization could cost up to 9450 before insurance covers everything else.
Medication Coverage and Formularies
A formulary is the list of medications your insurance covers.
Most Marketplace plans use tiered formularies.
Tier 1
Generic medications, lowest cost.
Tier 2
Preferred brand medications.
Tier 3
Non-preferred brand medications.
Tier 4
Specialty drugs, highest cost.
Important note:
Even heavily subsidized Marketplace plans may still have expensive brand-name medications if placed on higher tiers.
Resource:
What Changed in 2026 for Individuals
Key updates for 2026 include:
Out-of-pocket limits increased to their highest levels ever
Network shrinkage in many states
Some carriers added referral requirements
Many silver plans increased deductibles
Several medications changed tiers
More EPO plans introduced
Extended preventive telehealth benefits
Small shifts in subsidy brackets
Private carrier updates:
Nationwide PPO networks unchanged
Premiums increased only 2 to 4 percent
New underwritten plans added in several states
Better telehealth and wellness benefits
More flexible plan combinations
Marketplace Plans vs Private PPO Plans in 2026
Marketplace plans:
ACA compliant
Guaranteed approval
Subsidies available based on MAGI
Narrow networks common
High deductibles
Good for chronic conditions
Good for individuals needing guaranteed coverage regardless of health
Private PPO plans:
Require basic health questions
Broader networks
Often lower premiums than unsubsidized Marketplace plans
Flexible plan structure
Good for healthy individuals
Good for people who travel
Good option for individuals who do not qualify for subsidies
Best Plan Type Based on Your Situation
If you are healthy
A private PPO or an EPO may be a better long-term value.
If you travel often
Private PPO with nationwide access.
If you take specialty medications
Marketplace silver or gold plan.
If you have chronic conditions
Marketplace gold plan or silver CSR plan if eligible.
If you are self-employed
Private PPO or a hybrid combination of Marketplace plus supplemental coverage.
If you need low predictable costs
Marketplace gold plan with low out-of-pocket max.
Common Mistakes Individuals Make When Shopping
Choosing the lowest monthly premium only
Ignoring the network type
Not verifying drug coverage
Not estimating their income correctly for subsidies
Assuming all plans cover out-of-state care
Missing enrollment deadlines
Not comparing out-of-pocket maximums
Misunderstanding preventive vs diagnostic services
When You Should Consider Switching Coverage
You should consider switching if:
You lose employer coverage
Your marketplace subsidy changes
Your premiums increase
Your doctor leaves your network
You start traveling frequently
You are paying full price for Marketplace coverage
Your medications move to a higher tier
Your deductible becomes unaffordable
Trusted Resources for Individuals Doing Their Own Research
Healthcare.gov (definitions and consumer education)
Kaiser Family Foundation (unbiased plan data)
CMS Marketplace updates
State Department of Insurance websites (rate filings)
Search your state DOI
Final Thoughts
Health insurance for individuals in 2026 can feel overwhelming, but it does not have to be confusing. With the right information, you can choose a plan that fits your needs, protects your budget, and gives you confidence.
If you would like help reviewing your options, comparing Marketplace and private plans, or understanding how 2026 changes affect you, you can schedule a quick review with the link below.
Enjoying these insights?
Follow Coverage by Kuhl on Facebook for simple, honest health coverage tips, Marketplace updates, and private PPO guidance — posted weekly.
Written by Nicholas Kuhl
Licensed Health Advisor
Coverage By Kuhl
Great info!