US health insurance by age: from kids to Medicare

Coming from Europe, you are used to health coverage that is funded by income-based contributions or taxes, or priced much the same for every adult. In the USA the logic is different: your premium follows your age, where you live and whether you smoke. Someone arriving at 35 with two small children does very different math from a couple aged 58, and someone arriving at 66 does different math again, because that is where Medicare comes in, or doesn't. This guide walks through each stage of life in turn. How deductibles, coinsurance and networks work is covered on our pages about the US healthcare system; here we look at what your age and your immigration status do to the bill.

1Your age is your price

Since the healthcare reform, American insurers may factor only five things into the premium for individual and family plans: age, location, tobacco use, plan tier and whether a spouse or children are covered. Health status, pre-existing conditions and gender play no part, and pre-existing conditions are covered from day one (HealthCare.gov, How insurance companies set health premiums). For newcomers with a chronic condition, that is good news: nobody asks for your medical records before selling you a plan.

The bad news is in the first item. Older people can be charged up to three times what younger people pay; smokers up to 50 percent more (45 CFR 147,102). The shape of the curve in between is set by the federal government in a default model that applies in every state without its own curve. The table shows the factors: a 50-year-old pays almost double what a 21-year-old pays, a 64-year-old exactly three times as much. In between, the premium rises every year, noticeably faster from your mid-forties.

New York is the exception. Its law requires community rating: everyone on a plan pays the same premium, regardless of age, gender, health, tobacco use or occupation (New York Insurance Law § 4317). A 60-year-old there pays as much as a 25-year-old on the same plan. The actual premium level depends, as everywhere, on region and plan.

2Green card or visa: who gets subsidies

Whether you can buy coverage on the government Marketplace at all depends on your immigration status, but the rules are generous: besides green card holders, people with a valid nonimmigrant visa count as lawfully present, including E-2, L-1, H-1B and similar visas (HealthCare.gov, Immigration status to qualify for the Marketplace). So if you come on an investor or business visa, you can get insured on the Marketplace.

Whether you get subsidies is a different question. Following a change in the law, from January 1, 2027 the premium tax credit and the cost-sharing reductions will only be available to green card holders, Cuban and Haitian entrants and migrants from the Pacific states associated with the USA. Everyone else can still buy coverage, just without a subsidy (HealthCare.gov, Coverage for lawfully present immigrants). For a family on an E-2 or L-1 visa, that means: budget for the full price of the plan.

Even with a green card, you only get the subsidy with a household income between 100 and 400 percent of the poverty line. For reference: 400 percent of the 2026 poverty line is $63,840 for one person and $132,000 for a household of four (Department of Health and Human Services, Poverty Guidelines 2026). Earn more and you pay the full price. Why this threshold is a cliff and not a ramp is explained in our article on the 400 percent cliff.

So your immigration status is not just a visa question, it is also a cost-of-living question. Which visa suits you and which route leads to a green card is covered in our guide Green card for entrepreneurs.

3Family and children

On the Marketplace, a family premium is not a flat rate but the sum of each family member's premium. Of the children under 21, only the three oldest count; the fourth and any further child is covered at no extra cost (45 CFR 147,102). In the federal default model, children up to 14 carry a factor of 0.765, just over three quarters of a 21-year-old's premium. Parents pay according to their own age factor.

Children can generally stay on their parents' plan until their 26th birthday; on employer plans, even if they marry, move out or no longer count as a dependent for tax purposes. On a Marketplace plan, they stay covered until December 31 of the year they turn 26 (HealthCare.gov, How to get or stay on a parent's plan).

3.1CHIP for children

Families on lower incomes can turn to Medicaid and the children's program CHIP. In principle, both are open to green card holders, usually only after a five-year waiting period. States may waive the wait for lawfully present children and pregnant women (HealthCare.gov). Texas, Florida, California and New York enroll lawfully present children in CHIP; California and New York also cover pregnant women through Medicaid (Medicaid.gov, as of April 2, 2026). Whether your family qualifies on its income is up to the state. Before you apply, check with your immigration attorney whether using public programs could affect your path to a green card.

4From 50: the expensive years before Medicare

The years between 50 and 65 are the most expensive stage of life in the American system. The premium rises every year with the age factor, from 1.786 at 50 to 3.000 at 64, so by about two thirds within 14 years, on the same plan in the same region. Medicare only kicks in at 65, and only under conditions explained in the next section. Move over at 55, and you are paying your own way on the open market for ten years, with no employer and on a visa that gets no subsidy.

Two rules help with timing. Moving to the USA from abroad gives you a special enrollment period: a move qualifies, and the usual requirement of prior coverage counts as met if you lived abroad during the preceding 60 days. You generally have 60 days from the move to choose a plan (45 CFR 155,420). Outside that window, you can only get a Marketplace plan during annual open enrollment; through HealthCare.gov, as in Texas and Florida, it runs from November 1 to January 15 (HealthCare.gov).

If you are employed by your own US company or work for one, also look at the employer's group plan. Employer plans follow their own rules. Some people bridge the first months with international health insurance. Before you sign up, check whether it counts as full coverage under your state's rules; in California, that decides whether you pay a penalty through your tax return (Franchise Tax Board).

5Retirees and Medicare

Without the quarters, you can buy into Medicare. But the law only allows buying Part A and enrolling in Part B for US citizens and green card holders who have lived in the USA continuously for the five years before enrolling (42 CFR 406.20 and 407.10). If you live in the USA on a visa, this route into Medicare is closed.

The table shows what buying in costs: in 2026, Part A is $311 a month with 30 to 39 quarters and $565 with fewer, and Part B is $202.90. On top of that come deductibles, such as $1,736 per hospital stay and $283 a year for Part B (CMS). And Medicare does not cover everything: deductibles and copays stay with you.

5.1The deadlines

You can enroll during a seven-month window: the three months before the month of your 65th birthday, that month itself and the three months after. Miss it without a special enrollment period, and you pay a Part B surcharge of 10 percent for every full twelve-month period in which you could have enrolled, for as long as you have Part B. If you have to buy Part A and enroll late, you pay 10 percent more for twice as many years as you waited (Medicare.gov).

7The four big destination states compared

Texas and Florida use the federal marketplace, HealthCare.gov. California runs its own marketplace, Covered California, where enrollment for 2027 runs from November 1 to January 31 (Covered California). Since 2020, California has also required health insurance: if you are uninsured and have no exemption, you pay a penalty through your state tax return. For 2025 that is at least $950 per adult and $475 per child, or 2.5 percent of income above the filing threshold, whichever is higher (Franchise Tax Board). New York also has its own marketplace, NY State of Health, and uses no age factor at all.

Health insurance alone won't decide which state is right for you, but it belongs in the calculation alongside taxes, schools and cost of living. More on this in our guide Which state is right for you.

8The order in which to decide

• Sort out your immigration status first. It determines subsidies, Medicare and children's programs.
• Calculate the premium using every family member's age in the year of the move and the years after, not their age today.
• Time your move so you can use the 60-day special enrollment period, or bridge the gap until the next enrollment period.
• Don't cancel your insurance at home until your US coverage is in place, and ask about keeping a right to rejoin.
• From 63, plan your Medicare enrollment: status, quarters, and the seven-month window around your 65th birthday.

Everything else to handle in your first 90 days is in the checklist Arriving in the USA, and how to find a doctor who takes your plan is in the guide Finding a doctor and dentist.

In short

• In the USA, only age, location, tobacco use, plan tier and whether family members are covered affect the premium. Your health doesn't count, but age can triple it; only in New York does everyone pay the same.
• From January 1, 2027, only green card holders and a few other groups will get marketplace subsidies. On an E-2, L-1 or H-1B you can still get covered, but you pay full price.
• For families, at most the three oldest children under 21 count toward the premium, and children stay on their parents' plan until 26. Texas, Florida, California and New York enroll lawfully residing children in CHIP, depending on income.
• Medicare starts at 65: Part A is premium-free with 40 quarters of US Social Security contributions; otherwise US citizens and green card holders can buy in after five years of continuous residence. In 2026, Part A then costs up to $565 a month and Part B $202.90.

How we help you

• ConsultationOne hour with the firm: your case, your questions, a clear answer.
• Visa RoadmapIn writing: which visa fits you and your family, prepared with the immigration attorney on the firm's team.
• Moving to the USAVisa, bank account, taxes and where to live: your move with Mount Bonnell Advisors.
• Your US Tax ReturnForm 1040 or 1040-NR, handled in English.