Who is eligible for individual health insurance?

Individual health insurance through the Affordable Care Act’s Health Insurance Marketplace and private exchanges allows people and families to get comprehensive coverage, often with financial help based on income.

In this article, we’ll explain who’s eligible, how enrollment works, and how HRAs are helping more employees get covered.

In this blog post, you'll learn:

• The difference between the annual Open Enrollment period and special enrollment periods (SEPs).
• The life-changing events that trigger SEPs.
• How health reimbursement arrangements (HRAs) like the individual coverage HRA (ICHRA) are driving people to enroll in individual health insurance plans.

What is individual health insurance?

Individual health insurance is a type of plan where you pick coverage for yourself and your dependents instead of enrolling in an employer’s one-size-fits-all group plan.

You have several ways to get a plan:

• Through your state’s health insurance exchange or the federal Health Insurance Marketplace.
• Directly from an insurance company or through a private exchange.
• Through a licensed insurance broker or insurance agent.

Learn all about individual health insurance in our article.

Eligibility requirements

Before you can enroll in an individual health insurance plan, there are a few key requirements you must meet. These rules ensure you’re legally able to purchase coverage through the Marketplace and private exchanges.

To be eligible for an individual health plan, you must¹:

• Live in the United States. Health coverage is only offered within the 50 states and Washington, D.C.
• Be a U.S. citizen, U.S. national, or lawfully present. This includes people with certain immigration statuses who are legally in the U.S., such as green card holders, refugees, and certain visa holders.
• Not be incarcerated. You can't be in jail, though you may still get coverage if you’re awaiting trial or a court decision.

Can't have Medicare coverage. If you qualify for or already have premium-free Medicare Part A, you generally aren’t eligible to enroll in an individual health insurance plan through the Marketplace or any other exchange.

Income limits

While anyone who meets the basic eligibility requirements can buy a Marketplace plan, your income plays a key role in determining whether you qualify for financial assistance, like premium tax credits or cost‑sharing reductions. Your income also determines if you qualify for Medicaid or CHIP.

The Marketplace uses your income, measured as modified adjusted gross income (MAGI), and federal poverty levels (FPL) to determine eligibility for cost savings².

State residency requirements

You must live in the state where you’re buying a health plan. Each state’s service area determines coverage availability, even if you apply on HealthCare.gov or a private exchange.

Enrollment

You can’t enroll at any time. Limiting enrollment periods prevents "adverse selection," when people only sign up after getting sick or needing expensive care.

You can apply for coverage during³:

• Open Enrollment. A set annual window, typically November 1 through December 15 (starting in 2026 for 2027 coverage⁴), when anyone eligible can enroll or change health plans. Under the new 2025 federal rules, states with their own exchanges may only extend this window to December 31. Previously, you could sign up in some states until the end of January.
• Special enrollment period. If you miss Open Enrollment, you may still qualify for coverage if you experience a qualifying life event. Once you trigger an SEP, you typically have 60 days to enroll or change plans.

Qualifying life events that trigger SEPs

SEPs are crucial for enrolling outside the standard window. Here are some common situations that trigger SEP eligibility⁵:

Special circumstances

Some complex situations can also qualify as life-changing events that trigger SEPs.

They include:

• Major illness or natural disaster interfering with enrollment.
• Court‑ordered changes in dependents.
• Being a survivor of domestic violence or abandonment.

How ICHRAs are driving individual enrollment

In 2026, 23 million people signed up for Marketplace health insurance coverage, according to the Centers for Medicare & Medicaid Services (CMS)⁶. Health reimbursement arrangements (HRAs) like the ICHRA are playing a growing role in this trend. While enrollment dipped by 1.3 million from 2025 due to the expiration of enhanced premium tax credits, this still marked the second-largest Open Enrollment period ever.

ICHRAs are employer-funded health benefits that give employees flexibility. Instead of providing a traditional group health plan, employers provide a monthly allowance that employees can use toward individual health insurance premiums.

Here’s how ICHRAs are influencing eligibility and enrollment:

• Encourage coverage. Many employees who previously declined group plan coverage are enrolling in individual plans now that their employer switched to an ICHRA and contributes to the cost of their premiums. This makes coverage more affordable and predictable.
• Offer flexibility. Unlike traditional group plans, ICHRAs give employees a choice of which individual health insurance plan to purchase. This means employees can tailor coverage to their needs, whether they want lower premiums, broader networks, or specific benefits.

Conclusion

Eligibility for individual health insurance through the Marketplace hinges on residency, citizenship, and timing. ICHRAs are increasingly driving employees to enroll by offsetting costs and offering flexible coverage choices. Remodel Health helps employers confidently launch and manage ICHRAs, making it easier for employees to enroll in coverage.

This article was originally published on Jun 21, 2022. It was last updated on February 26, 2026.

References

1. HealthCare.gov: A quick guide to the Health Insurance Marketplace, eligibility

2. HealthCare.gov: Federal poverty level (FPL)

3. HealthCare.gov: A quick guide to the Health Insurance Marketplace, When can you get health insurance?

4. Federal Register: Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability

5. HealthCare.gov: Special enrollment opportunities

6. CMS: Marketplace 2026 Open Enrollment Period Report: National Snapshot