Uninsured US healthcare is brutal. One ER visit can clear $20,000. This guide walks through how US insurance actually works, what you're likely eligible for, and how SettleKit points you to the right plan for your visa, income, and state.
What to expect
01
Financial protection
Coverage caps your worst year. ACA plans limit out-of-pocket spending to about $9,450 per person per year.
02
60-day window
Getting lawful US status usually opens a Special Enrollment Period of 60 days to pick a Marketplace plan.
03
Employer or Marketplace
Most work visa holders get employer coverage after 30 to 90 days. Everyone else typically uses the ACA Marketplace.
04
Subsidies are real
If your income is modest, ACA premium tax credits can cut your monthly premium to a fraction of sticker price.
Before you compare plans, it helps to know what you're actually paying for, and why going without coverage is usually the most expensive choice on the menu.
What US health insurance actually is
Skipping coverage is a gamble, not a saving
One ambulance ride runs $1,000 to $3,000. An appendectomy runs $30,000 to $50,000 uninsured. A 3-day hospital stay routinely exceeds $50,000. Hospitals have to treat emergencies by law, but they will bill you afterward, and medical debt is the single biggest cause of personal bankruptcy in the US.
Most lawful permanent residents (green card holders) have to wait five years before they can qualify for federally-funded Medicaid. But refugees, asylees, Cuban and Haitian entrants, trafficking survivors, and COFA migrants are exempt and can apply straight away. A few states also cover lawfully residing children and pregnant people without the wait.
Who qualifies for what (quick reality check)
Not sure which coverage types you actually qualify for?
Before you enroll, get the paperwork ready and build a rough mental model of what a good plan looks like for your situation.
Documents you'll typically need
No SSN yet? You can still start
Marketplace applications accept an ITIN, and Healthcare.gov lets you begin an application and add the SSN later. Some employers will also start benefits enrollment before the SSN arrives. Don't let a missing SSN be the reason you miss the 60-day window.
If your income is under 250% of the federal poverty level, a Silver plan triggers Cost-Sharing Reductions on top of the normal premium subsidy. That can push the effective coverage level to Gold or better while keeping the premium near Bronze. Do not default to Bronze because the sticker price looks lowest.
Evaluating an employer plan: HDHP vs PPO, HSA vs FSA
Enrollment is time-boxed. Miss the window and you typically wait until next November, or you're stuck with limited short-term options.
Arriving in the US counts as a Qualifying Life Event. You have 60 days to enroll in a Marketplace plan. Once it's gone, your next window is Open Enrollment in November, potentially 10+ months without coverage. Put the deadline in your calendar the week you arrive.
Want to know which exchange to use and what subsidy you'd qualify for?
Employer enrollment and Medicaid: the parallel tracks
Don't skip employer coverage for the Marketplace
If your employer offers an 'affordable' plan (defined as less than ~9.12% of household income for self-only coverage), you usually can't get ACA Marketplace subsidies even if you'd prefer the Marketplace plan. Compare carefully. The employer plan is almost always the better deal for the primary employee.
Getting enrolled is step one. The harder learning curve is using the plan: finding in-network care, reading bills, and fighting anything that looks wrong.
Once you pay, getting refunds is much harder. Call the insurer first, get the EOB, ask for an itemized bill, and only pay what's clearly owed. Medical debt can usually be negotiated down 30 to 50% with a single phone call, especially if you pay in one lump.
Re-enrollment, qualifying life events, and switching plans
Had a life change or move? Check whether you need to update your plan.
Answer a few questions about your situation and SettleKit builds a step-by-step plan tailored to your visa, state, and timeline.
US health insurance is a monthly contract. You (and often your employer) pay a premium each month, and the insurer covers a negotiated share of your medical costs in return. Healthcare here isn't funded through taxes the way it is in most countries. Coverage is split across private plans, employer plans, and government programs (Medicaid, Medicare, CHIP).
Four numbers define almost every plan. The premium is what you pay every month just to have coverage, whether you use it or not. The deductible is what you pay out of pocket each year before the insurer starts sharing costs. Copays and coinsurance are your share of each visit or prescription after the deductible is met, either a flat fee like $30 per doctor visit or a percentage like 20% of the bill. The out-of-pocket maximum is a hard cap on what you'll spend in a year; ACA Marketplace plans cap this at roughly $9,450 per person in 2024.
A 'cheap' plan with a $7,000 deductible can easily cost you more than a 'pricey' plan with a $1,000 deductible. It depends on how much care you actually use. That's the trade-off every plan decision comes down to.
Most newcomers land in one of five buckets. Which one fits depends on your visa, your employer, your income, and your state.
Employer-sponsored (group) plans are the default for most full-time US employees. The employer pays a big chunk of the premium and the rest comes out of your paycheck pre-tax. Usually the best value if you qualify.
ACA Marketplace plans are individual plans sold on Healthcare.gov or a state exchange (Covered California, NY State of Health, and others). They're open to most lawfully present immigrants, and premium subsidies are available based on income.
Medicaid is free or low-cost government coverage for low-income residents. Most non-citizens face a 5-year waiting period, with important exceptions covered in the callout below.
Student health plans are offered (and often required) by universities for F-1 and J-1 students. Usually cheaper than Marketplace plans and easier to enroll in.
Short-term and travel medical plans are cheap bridge coverage. Usually they don't cover pre-existing conditions, preventive care, or maternity. Fine for a month-long gap; dangerous as a year-round plan.
Eligibility for each coverage type comes down to three things: your immigration status, your employment, and your household income.
H-1B, L-1, O-1, E-2, TN, and most work visas usually qualify you for employer coverage after a waiting period of 30 to 90 days. You're also eligible for ACA Marketplace plans.
F-1 and J-1 students are usually required to carry student health insurance through the school. ACA Marketplace is an option if the school plan isn't mandatory.
Green card holders (LPRs) are eligible for employer plans and ACA Marketplace from day one. Most federally-funded Medicaid is subject to a 5-year waiting period, though state rules and exemptions vary.
Refugees, asylees, and people on humanitarian statuses are eligible for Medicaid immediately, plus ACA Marketplace.
Dependents on H-4, L-2, J-2, and F-2 visas are usually covered through the primary visa holder's employer plan, or via the Marketplace.
Undocumented individuals generally are not eligible for ACA Marketplace or federal Medicaid. A few states (California, New York, Illinois) offer state-funded alternatives.
SettleKit personalizes this to your specific visa and state rather than the broad strokes above.
Enrollment, whether through an employer, the Marketplace, or Medicaid, mostly comes down to proving three things: who you are, that you're lawfully present, and what your income is.
For Marketplace and Medicaid applications, expect to provide an SSN (or ITIN if you don't qualify for an SSN yet) to verify identity and income. You'll need your immigration documents: I-94, visa stamp, EAD card, green card, or refugee/asylee documentation, depending on your status. You'll need proof of income (recent pay stubs, a signed offer letter, or last year's tax return); if you just arrived and have no US income yet, you'll estimate. You'll need household information covering the spouse and dependents you plan to cover, and whether they'll be on the same tax return. And you'll need employer plan details if applicable: whether an affordable employer plan is available to you, since that affects Marketplace subsidy eligibility.
For employer enrollment, HR usually handles the immigration verification. You mostly just fill out the benefits form and pick a plan.
A plan's network is the list of doctors, hospitals, and labs where it covers care. Step outside the network and you either pay full price or get nothing back. Network type matters more than most newcomers expect, especially before you've picked a doctor.
An HMO (Health Maintenance Organization) has the cheapest premiums. It requires a primary care doctor (PCP) who refers you to specialists, and out-of-network care is usually not covered at all.
A PPO (Preferred Provider Organization) is more expensive. No referrals needed, and out-of-network care is covered at a lower rate. Best if you want flexibility or travel often.
An EPO (Exclusive Provider Organization) is a middle ground. No referrals, but out-of-network is not covered except for emergencies.
An HDHP (High Deductible Health Plan) is not a network type but a tier. High deductible, low premium, paired with a tax-advantaged HSA (Health Savings Account). Good if you're healthy and can stash money; risky if you have chronic conditions.
Before locking in a plan, check whether your preferred hospital and any specialists you already see are in-network. Every major insurer has a provider-finder tool.
ACA plans are sorted into four 'metal' tiers that tell you the cost split between you and the insurer across a typical year.
Bronze plans have the insurer paying about 60% and you paying about 40%. Lowest premium, highest deductible. Good if you're healthy and want cheap catastrophic protection.
Silver plans have a roughly 70/30 split. Cost-Sharing Reductions kick in at Silver for incomes under 250% of the federal poverty level, which for many newcomers makes it the cheapest real-world plan. If your income qualifies for these reductions, a Silver plan can end up with Gold-or-better coverage at Bronze-like prices. Don't auto-pick Bronze just because the premium looks lowest.
Gold plans have a roughly 80/20 split. Higher premium, low deductible. Good if you expect regular care.
Platinum plans have a roughly 90/10 split. Highest premium, lowest out-of-pocket. Worth it only if you know you'll use a lot of care.
Federal poverty level benchmarks for 2025 are roughly $15,060 for a household of one and $20,440 for two. Premium tax credits phase out above 400% of FPL (roughly $60k single, $81k couple). Below that, your Marketplace premium is capped as a percentage of income, often far below sticker price.
If your employer offers coverage, you'll usually see two or three options: an HDHP paired with an HSA, a PPO, and sometimes a second PPO tier. Compare them on four things.
First, total annual cost. Add the yearly premium to a realistic estimate of the care you'll use. Not just the premium alone.
Second, deductible and out-of-pocket max. HDHPs have high deductibles ($1,600+ single, $3,200+ family in 2024) but lower premiums.
Third, HSA vs FSA. An HSA (pairs with HDHPs only) rolls over year-to-year, is triple-tax-advantaged, and is yours forever. An FSA is use-it-or-lose-it each year and tied to the employer. The HSA is one of the strongest tax-advantaged savings accounts available to US earners.
Fourth, network coverage for your doctors. Even a generous plan is useless if your preferred hospital is out-of-network.
If you're healthy, young, and earning well, an HDHP with an HSA is often the highest-value option. If you have a chronic condition, see specialists regularly, or are planning a pregnancy, a lower-deductible PPO usually wins despite the higher premium.
You can't enroll in Marketplace coverage whenever you want. There are three windows.
The Open Enrollment Period (OEP) is the annual window when anyone can enroll or switch plans. For 2026 coverage it ran November 1, 2025 to January 15, 2026 on Healthcare.gov (some state exchanges run longer). Enroll by December 15 for January 1 coverage; enroll by January 15 for February 1 coverage.
A Special Enrollment Period (SEP) is a 60-day window triggered by a qualifying life event. Gaining lawfully present status in the US is itself a qualifying event. Newcomers have 60 days from their arrival or status date to enroll through the Marketplace.
Medicaid, CHIP, and employer plans run year-round. Medicaid and CHIP accept applications any time of year if you're eligible. Employer plans have their own enrollment periods (usually the first 30 days after you start, then annually).
For employer enrollment, your HR contact usually sends a benefits-enrollment link in your first week. The deadline is typically 30 days from your start date. Miss it and you wait for Open Enrollment or a qualifying life event.
The Marketplace is the main path for newcomers who aren't on an employer plan and don't qualify for Medicaid yet.
Start by picking the right site. Most states use Healthcare.gov. A handful run their own exchange: California (Covered California), New York (NY State of Health), Washington, Colorado, Minnesota, New Jersey, Pennsylvania, and others. Using the wrong site means your application won't process.
Create an account and start the application. You'll enter household info, income estimate, immigration status, and zip code. The system calculates your subsidy in real time.
Compare plans. Filter by metal tier, network type, premium, deductible, and whether your preferred providers are in-network.
Enroll. Pick a plan, make your first premium payment, and your coverage starts on the 1st of the following month (or January 1 or February 1 during OEP).
If your income is unstable or you just arrived without US income, you'll estimate. If you end up earning more than you estimated, you may have to repay some subsidy at tax time; earn less and you'll get the difference back. Always update the Marketplace if your income changes materially mid-year.
If your employer offers coverage, this is usually the simplest and cheapest path. In your first week, HR gives you a benefits-enrollment portal (Workday, Zenefits, Gusto, and similar). Pick your plan tier, add dependents, choose HSA or FSA contributions, and submit before the deadline (usually 30 days). Coverage typically starts on the 1st of the month after a waiting period, often 30, 60, or 90 days from your start date; check your offer letter. Your share of the premium comes out of every paycheck, pre-tax.
Medicaid enrollment goes through your state's Medicaid or health-and-human-services portal, not Healthcare.gov, though Healthcare.gov will route you there if you seem eligible. Applications are accepted year-round. You'll submit income documentation, immigration status, and household size.
If you're inside the 5-year waiting period and not exempt, you generally can't get Medicaid. You may qualify for substantial ACA subsidies instead. A few states offer state-funded alternatives for ineligible immigrants; it varies a lot by state.
Every insurer has a provider-search tool. Use it before you book. An 'in-network' hospital can still send you in-network surgeons and out-of-network anesthesiologists in the same visit, so check each provider individually when the bill will be big.
For the first six months in the US, most people need a primary care physician (PCP) as their default doctor for checkups, refills, and referrals; HMO plans require you to designate one. You'll also want a dentist and an eye doctor, which are usually NOT covered by medical insurance; dental and vision are typically separate add-ons through employers or the Marketplace. And a pharmacy: most plans have preferred pharmacies (CVS, Walgreens, or a mail-order option) where copays are lowest. Check your plan's formulary for prescription costs.
Before any non-emergency visit, confirm three things: the provider is in-network, the specific facility is in-network, and any recommended tests will be processed by an in-network lab. Asking is boring. It also saves four-figure surprises.
After any visit, you'll get two documents a few weeks apart. They're easy to confuse.
The EOB (Explanation of Benefits) is sent by your insurer. This is not a bill. It shows what the provider charged, what the insurer paid, and what you owe.
The provider bill or statement is sent by the doctor or hospital. This is what you actually pay.
Line these up before paying anything. A few common catches. If the bill arrives before the insurer has processed the claim, wait for the EOB instead of paying blindly. If the bill charges more than the EOB says you owe, call the provider's billing office; this is often a system lag. If you see services billed that you didn't receive, ask for an itemized bill and dispute each line. If you see an out-of-network charge you weren't warned about, read the next section on the No Surprises Act.
Medical billing errors are common. Roughly 80% of itemized bills contain at least one mistake. Always ask for the itemized version before paying a large bill.
Since January 2022, the No Surprises Act has protected patients from most out-of-network surprise bills in three common scenarios.
Emergency care is covered: you cannot be balance-billed by an out-of-network ER, air ambulance, or out-of-network doctor at an in-network hospital for emergency treatment.
Non-emergency care at an in-network facility is covered: if you go to an in-network hospital for a planned procedure and get treated by an out-of-network anesthesiologist, radiologist, or pathologist, you're protected.
Air ambulance services are covered too; federal protection applies regardless of network.
If you get a surprise bill that seems to violate the NSA, don't pay immediately. Call your insurer and the provider to dispute. You can file a formal complaint with CMS through the No Surprises Help Desk (1-800-985-3059). The law also gives you an Independent Dispute Resolution (IDR) process for certain billing disputes.
Ground ambulances are a loophole. They are NOT covered by the federal NSA, though some states have their own protections.
Coverage isn't set-and-forget. Several things trigger changes.
Annual re-enrollment. Each fall, employers run an Open Enrollment window (usually October to November) for the following calendar year. Review new premiums, new plan options, and whether your doctors are still in-network. The Marketplace runs its own OEP from November 1 to January 15 in most states.
Qualifying life events. Marriage, divorce, new baby, job change, loss of coverage, moving to a new state, and changes in immigration status all trigger a 60-day Special Enrollment Period on the Marketplace. Employer plans have similar mid-year change windows.
Income changes. If your Marketplace subsidy was based on an income estimate and your actual income changes materially, update Healthcare.gov immediately. Otherwise you'll reconcile at tax time and may owe back.
Moving states. ACA plans are state-specific. Moving across state lines is itself a qualifying event, and you'll need to re-enroll on your new state's exchange.
Set a calendar reminder for every October: your employer's Open Enrollment is coming, and the auto-renewal default is often not your best option.
There's no federal penalty for being uninsured anymore; the ACA individual mandate penalty was cut to $0 in 2019. However, California, Massachusetts, New Jersey, Rhode Island, and Washington D.C. still have state-level mandates with penalties. Even without a mandate, going without coverage is financially reckless. One hospitalization can cost $50,000+, and medical debt is the #1 cause of personal bankruptcy in the US. For most newcomers, insurance isn't legally required but it's practically essential.
It depends on your status. Refugees, asylees, Cuban and Haitian entrants, trafficking survivors, and COFA migrants are eligible immediately if they meet income limits. Most lawful permanent residents (green card holders) face a 5-year waiting period before qualifying for federally-funded Medicaid. Temporary visa holders (H-1B, F-1, J-1, and similar) are generally not Medicaid-eligible. A few states such as California, New York, Illinois, and Washington offer state-funded coverage for some immigrants excluded from federal Medicaid. Rules are changing in 2026 and vary a lot by state.
It depends on your income and visa. If your employer offers coverage, that's almost always the cheapest option, because the employer pays the bulk of the premium. If you're Marketplace-bound and your income is modest, a Silver plan with Cost-Sharing Reductions is often the cheapest real-world plan thanks to ACA subsidies. For students, the university health plan is usually cheaper than the Marketplace. Avoid short-term plans as your main coverage; they're cheap because they don't cover much.
The Marketplace (Healthcare.gov or your state's exchange) is an online shop for individual health insurance plans. You enter your household, income, and zip code; the system tells you which subsidies you qualify for and shows you plans sorted into Bronze, Silver, Gold, and Platinum tiers. You pick one, pay the first premium, and coverage starts the 1st of the following month. Most lawfully present immigrants can use the Marketplace, and if your income is under about 400% of the federal poverty level, subsidies often cut the premium to a fraction of sticker price.
A deductible is the amount you pay out of pocket each year before insurance starts contributing (for example, the first $2,000 of medical bills are all yours). A copay is a flat fee you pay for specific services after the deductible is met ($30 per doctor visit, $10 per generic prescription). Coinsurance is similar to a copay but it's a percentage (you pay 20% of the bill, insurer pays 80%). The out-of-pocket maximum caps everything; once you hit it, insurance covers 100% for the rest of the year.
Hospitals have to stabilize you in an emergency regardless of insurance, but they will bill you afterward. Uninsured emergency bills routinely run $10,000 to $100,000+. You can sometimes negotiate these down 30 to 70% by asking for a 'self-pay discount' or requesting an itemized bill, but many people end up in medical debt or bankruptcy. Non-emergency care without insurance means paying full cash prices (often 2 to 5 times what insurers pay). The math almost never favors going uninsured.
Usually no, or only partially. Most home-country insurance either doesn't cover care outside the country or covers it at very limited rates and forces you to pay upfront and claim later. Some premium international plans (for example, expat health insurance) do cover US care, but they're expensive and often have high deductibles. A common bridge is travel medical insurance for your first 30 to 90 days while you arrange permanent US coverage. Don't rely on travel medical as a long-term plan, since it excludes pre-existing conditions and routine care.
If you're starting a job, your employer will tell you the enrollment deadline (typically 30 days from start date). If you're using the ACA Marketplace, getting lawfully present status opens a 60-day Special Enrollment Period, so you have 60 days from arrival or status to enroll. Miss the 60-day window and you usually wait until the next Open Enrollment Period (November 1 to January 15 in most states), potentially leaving you uninsured for months. Put the deadline in your calendar the week you arrive.
