Self-employed health insurance plans bought on the ACA Marketplace or off-exchange must include the 10 essential health benefits, such as doctor visits, emergency care, hospitalization, maternity care, mental health, prescriptions, and $0 in-network preventive care. They usually do not include adult dental, adult vision, or long-term care, which require separate plans.
One of the most common questions self-employed Floridians have when shopping for health insurance on the marketplace is a deceptively simple one: what does this plan actually cover? Unlike employer group plans where HR hands you a summary and answers questions, marketplace shopping puts that research on you. The good news is that ACA plans have a well-defined baseline — every plan sold on healthcare.gov is legally required to cover the same core services. Understanding what’s included (and what isn’t) makes it much easier to compare plans, pick the right metal tier, and avoid surprises when you actually need care.
The 10 Essential Health Benefits: What Every ACA Plan Must Cover
Under the Affordable Care Act, all marketplace-compliant health plans must cover ten categories of services — known as Essential Health Benefits (EHBs). These apply to every carrier in Florida, whether you’re buying through Florida Blue, Ambetter, Oscar, UnitedHealthcare, or any other marketplace insurer. The ten categories are:
- Ambulatory (outpatient) services: Doctor visits, specialist care, urgent care, and outpatient procedures
- Emergency services: ER visits, including out-of-network emergencies — plans cannot charge more than in-network cost-sharing for ER visits
- Hospitalization: Inpatient surgery, overnight stays, and associated care
- Maternity and newborn care: Prenatal visits, labor and delivery, and postpartum care
- Mental health and substance use disorder services: Therapy, psychiatric care, inpatient behavioral health, and substance use treatment
- Prescription drugs: Coverage across a formulary (the plan’s approved drug list), with tiered copays
- Rehabilitative and habilitative services and devices: Physical therapy, occupational therapy, speech therapy, and medically necessary devices
- Laboratory services: Blood tests, imaging, pathology, and diagnostic work
- Preventive and wellness services: Annual physicals, cancer screenings, immunizations, and chronic disease management
- Pediatric services: Including dental and vision care for children under 19
These benefits must be covered on every ACA plan sold in Florida. A plan cannot legally eliminate any of these categories.
Preventive Care at Zero Cost
One of the most valuable features of ACA plans — and one that gets underused — is that a defined set of preventive services must be covered at $0 cost-sharing when you receive them in-network. This applies regardless of whether you’ve met your deductible.
Services covered at no cost include:
- Annual wellness visits and routine physicals
- Recommended immunizations (flu, COVID-19, shingles, pneumonia, etc.)
- Cancer screenings: mammograms, colonoscopies, low-dose CT lung screening for smokers
- Blood pressure and cholesterol checks
- Depression and anxiety screenings
- Diabetes screenings for at-risk adults
- Certain preventive medications (statins for cardiovascular risk, PrEP for HIV prevention)
For self-employed Floridians who may be tempted to skip routine care to avoid costs, this is important: those visits cost you nothing beyond your premium. Use them.
Prescription Drug Coverage
Every ACA plan must cover prescription drugs, but the specifics vary by plan. Each carrier maintains a formulary — a tiered list of covered medications with different copays at each tier. Typically:
- Tier 1: Generic drugs — lowest copay
- Tier 2: Preferred brand-name drugs — moderate copay
- Tier 3: Non-preferred brands — higher copay
- Tier 4: Specialty drugs — often coinsurance rather than flat copay
ACA plans must cover at least one drug in every United States Pharmacopeia (USP) category and class, and must cover certain USPSTF-recommended preventive medications at no cost. If you take a specific medication, check the formulary for any plan you’re considering — it’s available on the carrier’s website and on healthcare.gov.
Mental Health Parity
The Mental Health Parity and Addiction Equity Act requires that mental health and substance use disorder benefits be covered on par with medical and surgical benefits. In practical terms, this means a plan cannot charge you a higher copay to see a therapist than it charges to see a primary care physician, and it cannot impose stricter visit limits on mental health services than it applies to comparable medical services.
For self-employed Floridians — who often deal with the financial stress and isolation that comes with running their own business — this is meaningful. See mental health coverage in self-employed plans. Mental health coverage is real coverage, not a second-tier benefit.
What’s NOT Covered: The Gaps You Need to Know
ACA plans cover a lot, but they do not cover everything. Standard health insurance in Florida does not include:
- Adult dental care: Routine cleanings, fillings, crowns, and orthodontics require a separate dental plan
- Adult vision care: Eye exams, glasses, and contact lenses are not covered (separate vision plan needed)
- Long-term care: Nursing home stays and in-home custodial care require separate long-term care coverage
- Cosmetic procedures: Unless medically necessary (e.g., reconstructive surgery after an accident)
- Experimental or investigational treatments: Clinical trial coverage exists under some plans but is limited
If you need adult dental or vision coverage, these are straightforward add-ons that many Florida carriers offer as standalone plans or bundled riders; see how self-employed people get vision and dental coverage and our supplemental products.
Understanding Metal Tiers: Bronze, Silver, Gold, Platinum
One of the most important things to understand when shopping on the Florida marketplace is that all four metal tiers cover the same 10 essential health benefits. The tiers do not change what is covered — they change how costs are shared between you and the plan. Every tier is subject to the federal out-of-pocket cap: $10,600 individual / $21,200 family for 2026 and $12,000 / $24,000 for 2027. For help choosing, see Bronze vs. Silver vs. Gold when self-employed.
- Bronze: Lowest premium, highest deductible and out-of-pocket costs. Best if you’re healthy and rarely need care. Many Bronze plans are HSA-eligible HDHPs.
- Silver: Mid-range premium and cost-sharing. The only tier that qualifies for Cost-Sharing Reductions if your income is 100–250% of FPL — making Silver the best value for many self-employed Floridians in that income range.
- Gold: Higher premium, lower out-of-pocket costs. Makes sense if you anticipate frequent care or have ongoing prescriptions.
- Platinum: Highest premium, lowest cost-sharing. Rarely available in Florida markets but designed for high healthcare utilizers.
HSA-Compatible Plans: A Tax Advantage for the Self-Employed
If you choose a High-Deductible Health Plan (HDHP) — typically a Bronze plan — you may be eligible to open a Health Savings Account (HSA). HSAs allow you to contribute pre-tax dollars to cover qualified medical expenses. In 2026, the contribution limit is $4,400 for self-only coverage and $8,750 for a family, rising to $4,500 and $9,000 in 2027, plus a $1,000 catch-up at age 55. For 2027, an HSA-qualified plan must have a deductible of at least $1,750 self-only or $3,500 family. That money rolls over year to year and can be invested — and for the self-employed, it’s one of the few remaining tax-advantaged accounts available outside of retirement savings.
Florida Marketplace Carriers: What Each Brings
In the Florida marketplace, you’ll typically encounter these major carriers, each with distinct strengths:
- Florida Blue: The state’s dominant carrier with the most comprehensive provider network — particularly strong in Central Florida and across Volusia County
- Ambetter: Competitively priced plans, especially at the Silver tier; good option for subsidy-eligible Floridians focused on premium cost
- Oscar: Known for a strong digital experience and robust telehealth benefits — useful for self-employed people with unpredictable schedules
- UnitedHealthcare, AvMed, AmeriHealth Caritas, and 22 Health: Available in select counties with varying networks and pricing
Cigna and Molina are leaving Florida’s individual market for 2027. If you have one of their plans, pick a replacement during Open Enrollment (November 1, 2026 – January 15, 2027; enroll by December 15 for January 1 coverage).
Network size, formulary, and provider availability vary by county — what’s available in DeLand or Deltona may differ from Jacksonville or Tampa. Checking whether your current doctors are in-network before you enroll is always the right move.
Talk to a Broker Who Knows the Florida Market
Frequently Asked Questions
What do self-employed health insurance plans cover?
ACA-compliant plans for self-employed people cover the 10 essential health benefits: outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance use treatment, prescription drugs, rehabilitative services, lab work, preventive care, and pediatric services including children’s dental and vision. Coverage is the same whether you buy on or off the Marketplace.
Do self-employed health plans include dental and vision?
Adult dental and vision are not essential health benefits, so most ACA medical plans do not include them. Pediatric dental and vision for children under 19 are covered. Adults can buy standalone dental and vision plans or add-on riders, which many Florida carriers offer.
Do all metal tiers cover the same services?
Yes. Bronze, Silver, Gold, and Platinum plans all cover the same essential health benefits. The tiers differ in how costs are split: Bronze has the lowest premiums and highest out-of-pocket costs, while Gold and Platinum cost more monthly but less when you use care. Only Silver plans carry cost-sharing reductions for eligible incomes.
What are the HSA limits for self-employed people?
If you enroll in an HSA-qualified high-deductible plan, you can contribute up to $4,400 self-only or $8,750 family for 2026, and $4,500 or $9,000 for 2027, plus a $1,000 catch-up if you are 55 or older. Contributions are tax-deductible, and qualified medical withdrawals are tax-free.
Want to make sure your coverage actually covers what you need before a claim happens? Talk with Michael McAllister, owner of Choice Health Insurance Brokers in DeLand and a licensed broker appointed with 200 carriers (NPN 18229135). Call or text 321-230-9536 or visit choice.healthcare to get started.