Health insurance when you work for yourself
Most self-employed people should start by checking a Marketplace plan, since savings depend on income and it cannot turn you down for a health condition. If you earn too much for savings and are in good health, an underwritten private plan may cost less but gives up protections. Short-term plans, fixed indemnity plans, and sharing ministries each have serious limits.
Sam to confirm: review and sign off on this guide
Are you self-employed for health insurance purposes?
HealthCare.gov says you are self-employed if your business takes in income but has no employees. That covers freelancers, consultants, independent contractors, and other solo workers, and all of them can use the Marketplace. If your business has even one employee other than yourself, a spouse, family member, or owner, you may be able to use the SHOP Marketplace instead.
The five kinds of coverage
| Type | What it is | Pre-existing conditions | Wrong choice if |
|---|---|---|---|
| Marketplace (ACA) plan | Comprehensive coverage with 10 essential health benefits, sold through HealthCare.gov or your state marketplace. Savings depend on income. Source | Covered. A plan cannot reject you or charge you more because of a condition you already had. Source | You earn too much for savings, the premium is out of reach, or your doctors are not in the network. |
| Underwritten private plan | A private plan sold outside the Marketplace. The insurer asks health questions and decides whether to offer coverage and on what terms. Source (pre-ACA definition) | Can be declined, excluded, or limited, depending on your answers and the plan. | You have an ongoing condition, are planning a pregnancy, or could not afford a large gap in coverage. |
| Short-term plan | Temporary coverage for a gap. In Maryland it ends after three months and cannot be renewed. Other states differ. Source | May not pay for anything related to a pre-existing condition. It can also ask health questions. | You need more than a short bridge, or you need prescriptions or maternity care. Maryland does not require either. |
| Fixed indemnity plan | Pays set dollar amounts per day or per service, rather than a share of the bill. It is not comprehensive coverage. Source | Varies by policy. Read the exclusions. | It would be your only coverage and a large hospital bill would hurt. |
| Health care sharing ministry | Members share medical costs. It is not insurance and cannot guarantee that a claim gets paid. Source | Often limited by the program's rules. | You want a guarantee of payment or the protections of state insurance law. |
Why the math changed
The enhanced premium tax credits expired at the end of 2025. KFF's May 2026 analysis found that premium payments rose an average of 58% in 2026, from $113 to $178 a month, across all consumers. Some of that increase was held down because people moved to higher-deductible plans or dropped coverage, so a lower payment may also mean a higher deductible. Some states added their own help. For 2027, Maryland says residents with incomes up to 400% of the poverty level may qualify for state premium assistance.
What to do now that the enhanced credits are gone
How to choose, in four questions
1. What would the Marketplace cost you?
Get this number first, even if you expect to buy something else. It is the comparison every other option has to beat. Savings are based on your estimated net self-employment income for the year you are getting coverage, not last year.
2. Could you pass health questions, today and next year?
Plans that ask health questions can look far cheaper because they can turn away people who cost more. As Sam wrote on his old blog, "we are not denying that there is a need for the current marketplace plans." If you have an ongoing condition, the Marketplace may be the only option that covers it fully.
3. What does a bad year cost you?
Compare the out-of-pocket maximum, any benefit caps, and how hospital bills get paid. A low premium with a fixed benefit can leave a large balance after a hospital stay.
4. Are your doctors and prescriptions covered?
Check by name, in writing. Network size and drug coverage vary widely.
Price the Marketplace first. Look outside it only if you understand what you are giving up. Get anything important in writing.
When to enroll
For 2027 coverage, Open Enrollment on HealthCare.gov runs from November 1, 2026 to January 15, 2027. Enroll by December 15 for coverage that starts January 1. Maryland Health Connection uses the same window, and enrolling by December 31 gets you a January 1 start. After that, you generally need a qualifying life event. Some plans outside the Marketplace accept applications year-round.
Your premiums may be deductible
If you had a net profit from self-employment and could not join a subsidized employer plan, the IRS generally lets you deduct premiums for yourself, your spouse, and your dependents. Its Form 7206 instructions explain the rules. Read how the deduction works.