Choose the best health plan for your situation:
- As a result of the American Rescue Plan, enrollees may want to reconsider their plan choice for 2021
- Determine your worst-case scenario
- Use deductibles and coinsurance for a back-of-the-envelope comparison
- Don’t get enamored with low out-of-pocket expenses on more robust plans
- If your plan has tiered networks, pay attention to out-of-pocket costs
- Silver plans are popular for a reason (CSR subsidies)
- CSR pricing variations might make Gold a better value in some areas
- Remember: one size does not fit all
When it comes to selecting a health insurance plan, the premium is the most important factor for many shoppers – especially those who are currently healthy. But price shouldn’t be the only factor upon which you base your selection, even if your primary concern is financial (as opposed to factors such as provider networks, drug formularies, and quality ratings).
Does the American Rescue Plan change anything about choosing a health plan?
The temporary subsidy enhancements created by the American Rescue Plan (ARP) make it more important than ever for people to actively consider their coverage for 2021 and 2022, to ensure that they’re getting the best possible value from their health coverage.
The ongoing COVID-related enrollment period, which currently extends through August 15, 2021 in most states, is an opportunity for uninsured Americans to enroll in health coverage through the marketplace/exchange. In almost all states, it’s also an opportunity for current marketplace enrollees to switch to a different plan. If you’re considering switching plans, however, you’ll want to check with your insurer to see whether they’ll allow a carryover credit for any out-of-pocket costs you’ve already accumulated in 2021, assuming you’re considering a switch to another plan offered by the same insurer.
If you’re currently enrolled in an off-exchange plan (because you weren’t previously eligible for subsidies) or you’ve got a Bronze plan because it was the option that fit your budget under the normal subsidy rules, you’ll want to take a second look one the new subsidy amounts are available on the marketplace in your state. You might find that you’re newly eligible for a subsidy in 2021 and 2022, or that you qualify for a larger subsidy that makes a more robust plan fit into your budget. If you’re receiving unemployment compensation, you’ll want to consider the available Silver plans, as you’ll likely qualify for at least two of them (the benchmark plan and the lowest-cost Silver plan) with $0 premium and robust cost-sharing reductions.
The additional premium subsidies are retroactive to January 1, 2021 for people who have had marketplace coverage all year. If you enroll in a plan before your state’s marketplace has the new subsidies built into its calculations, you’ll be able to claim them on your 2021 tax return or log back into your marketplace account later on and follow the instructions to activate the new subsidy amounts in real-time. But you’ll need to make sure you’re enrolled in a marketplace plan (and the option that best fits your needs and budget) in order to take advantage of the enhanced subsidies.
Determine your worst-case scenario.
The worst-case scenario is pretty easy to determine. Just add the total annual premiums plus the maximum out-of-pocket for each plan, and see how they stack up. If you qualify for a premium subsidy (keeping in mind that they’re larger and more widely available in 2021 and 2022, due to the ARP), be sure to use the after-subsidy premium for each plan when you’re calculating how much the coverage will cost (you can find this even before you create an account with the exchange, by using the exchange’s plan browsing tool; it only takes a minute or two and doesn’t need any identifying data; the regular additional subsidies under the ARP began to be available in most states as of April, but for people who are receiving unemployment benefits in 2021, the additional subsidy amounts under the ARP are expected to be displayed on HealthCare.gov as of July 2021, and there are varying dates for this among the state-run exchanges).
The ACA’s limit on out-of-pocket maximums makes this sort of financial comparison easier than it was in the past. In 2021, no ACA-compliant plan has a maximum out-of-pocket that exceeds $8,550 for an individual or $17,100 for a family. And as has been the case since 2016, all family plans are required to have embedded individual out-of-pocket maximums. That means no single individual on a family plan will be required to pay more than $8,550 in out-of-pocket costs for in-network care, even if the family deductible has not yet been met.
But some plans – especially at the Gold and Platinum level, plus Silver-level plans for people who qualify for cost-sharing reductions – have maximum out-of-pocket limits that are significantly lower than those amounts. And they also cover more expenses before the out-of-pocket maximum is reached. Those factors are important to consider when you’re comparing the overall cost of various plans.
Let’s look at a hypothetical example for Kelly, a single 35-year-old applicant who doesn’t qualify for subsidies (even under the ARP, this is possible; it depends on the cost of the benchmark plan relative to household income; although more people qualify for subsidies under the ARP, some still do not). She’s considering three different plans – one Bronze, one Silver, and one Gold. All of them cover preventive care at no charge, as required by the ACA.
For this comparison, we’re assuming the Gold plan is more expensive than the Silver plan. But since 2018, that hasn’t always been the case, due to the cost of cost-sharing reductions (CSR) being added to Silver plan premiums in many states.
The following plan descriptions are overly simplified in order to make the math easy. Although Bronze, Silver, and Gold plans pay an average of 60, 70, and 80% of average total healthcare costs, respectively, their plan structure varies significantly from one policy to another, even within the same metal level. Some state-run exchanges offer standardized plans, and California’s exchange requires all plans to be standardized. But in most states, it can be challenging to make an apples-to-apples comparison of plans, even within the same metal level.
Some plans have separate deductibles for services like hospitalizations and prescription drugs, some have copays for office visits while others count office visits towards the deductible. There’s no way to really compare plans without reading at least some of the fine print. But for the sake of our back-of-the-envelope comparison, we’ll just look at deductibles, coinsurance, and maximum out-of-pocket exposure.
- The Bronze plan is $270/month, and has a $7,500 deductible with all claims applied to the deductible. After the deductible, Kelly would pay 40% of her claims until she reaches an $8,550 maximum out-of-pocket.
- The Silver plan is $350/month, has a $3,000 deductible, and Kelly will be responsible for 30% of the claim after the deductible, until she reaches a $7,000 maximum out-of-pocket.
- The Gold plan is $420/month, has a $1,000 deductible, and Kelly will pay 20% of her claims after the deductible until she reaches the maximum out-of-pocket of $3,500.
We can easily calculate the worst-case scenario for the three plans: Multiply the premium by 12 months, and add it to the maximum out-of-pocket to see the total financial exposure for each plan:
- Bronze: $3,240 + $8,550 = $11,790
- Silver: $4,200 + $7,000 = $11,200
- Gold: $5,040 + $3,500 = $8,540
But for most people, large claims don’t happen very often. And although some people may not use their coverage at all during the year, most people fall somewhere in the middle. Especially if you have a pre-existing condition, you can be relatively sure that you’ll incur at least some claims during the coming year. That’s where it’s helpful to judge each plan based on how it would perform in the event of relatively minor – but still expensive – claims.
What if Kelly breaks her arm and incurs a claim that totals $4,200 after the network-negotiated discount? Here’s her total expense for the year (premiums + out-of-pocket costs) with each plan:
- Bronze: $3,240 + $4,200 (total claim applied to the deductible) = $7,440
- Silver: $4,200 + $3,000 (deductible) + $360 (30% of the remaining $1,200) = $7,560
- Gold: $5,040 + $1,000 (deductible) + $640 (20% of the remaining $3,200) = $6,680
If the only health insurance claims you make are for preventive care, a Bronze plan is going to end up being the least expensive option, because the premiums are lowest and preventive care is covered 100 percent on all plans. But if you have other claims, a plan with a higher metal level might save you money over the course of the year, even though the premiums are higher. So even if price is the most significant factor in your decision, it’s important to remember to include the cost of a claim as well as the cost of the plan itself.
But don’t focus entirely on the cost of claims
On the other hand, don’t let yourself get so enamored with the low out-of-pocket expenses on the more robust plans that you inadvertently end up paying more than you need to. We often see plan comparisons where the difference in premium is greater than the difference in potential out-of-pocket savings.
For example: a plan with a deductible that is $1,000 lower than a competing plan, but that costs $100 more per month and offers similar coverage after the deductible. Buying it would mean that you’d spend an extra $1,200 in premiums, to possibly save $1,000 if you have a significant claim. That’s why it’s important to spend a little time crunching numbers before you select a plan.
And if one of the plans you’re considering is HSA-qualified, don’t forget to account for the tax savings you’d get if you contribute to an HSA during the year. Assuming you’d be willing and able to make contributions to an HSA, you’d want to subtract the tax savings from the total amount that each plan is going to cost you, so that you can get an accurate overall picture of how each plan would affect your finances.
If your plan has tiered networks, pay attention to out-of-pocket costs
It’s also important to be aware that some plans have tiered networks, which have lower copays and deductibles as long as you go to doctors and hospitals in the top tier. There’s some controversy around tiered network plans, but they tend to be popular with consumers, as they offer a good combination of low cost-sharing (assuming the patient sticks with top-tier providers) and affordable premiums.
If you’re considering a plan with a tiered network, pay attention to the out-of-pocket costs for both the preferred and non-preferred provider tiers, and crunch the numbers both ways. If you pick a plan with a tiered network, your best bet will be to use doctors and hospitals in the top tier. But it’s important to also understand what your costs will be if you end up needing to see in-network providers who aren’t in the top tier.
Silver plans’ cost-sharing subsidies
Silver plans have proven to be by far the most popular choice in the exchanges, accounting for roughly two-thirds of all enrollments in the first four years of ACA implementation. Silver plan enrollments dropped off a little in recent years (we’ll get into the reason for that in a moment), but are likely to grow during the COVID-related enrollment period in 2021, thanks to the ARP’s much more robust premium subsidies:
- In 2014, 65% of people who enrolled through HealthCare.gov (the federally-run exchange) selected Silver plans, and 95% of those Silver plans included financial assistance.
- In 2015, Silver plans accounted for 69% of HealthCare.gov enrollees.
- 71% of HealthCare.gov enrollees picked Silver plans for 2016, along with 59% of enrollees in states with their own enrollment platforms.
- 71% of exchange enrollees picked Silver plans in 2017.
- 63% of exchange enrollees picked Silver plans in 2018.
- 59% of exchange enrollees picked Silver plans in 2019.
- 57% of exchange enrollees picked Silver plans in 2020.
- 55% of exchange enrollees picked Silver plans in 2021.
One reason for the popularity of Silver plans – and the high percentage of Silver plan enrollees who received premium subsidies – is cost-sharing reductions, or CSR (also known as cost-sharing subsidies). If your household income does not exceed 250% of poverty, you’re eligible for cost-sharing subsidies in addition to premium subsidies (premium subsidies apply to virtually everyone who receives cost-sharing subsidies, but they also extend to people with higher incomes, up to 400% of the poverty level in normal years, and to anyone who would otherwise have to pay more than 8.5% of their income for the benchmark plan in 2021 and 2022). During the open enrollment period for 2021 health plans, 12 million people enrolled in plans through the exchange, and nearly 5.7 million of them enrolled in plans with built-in CSR benefits.
For 2021 coverage, 250% of the poverty level is $31,900 for a single individual, and $65,500 for a family of four. The CSR benefits are strongest, however, for people with income that doesn’t exceed 200% of the poverty level, which is $25,520 for a single person, and $52,400 for a family of four (this is all based on the 2020 poverty level numbers, which are used to determine subsidy eligibility for 2021 coverage). Although the Trump administration announced in October 2017 that funding for cost-sharing subsidies would be discontinued, the cost-sharing subsidies themselves continue to be available, and that’s still the case for 2021.
The cost-sharing subsidies are automatically included in Silver plans for enrollees whose income makes them eligible to receive cost-sharing subsidies, which includes most people receiving unemployment compensation in 2021. Cost-sharing subsidies are not available at the other metal levels, and do not show up among the available plan selections for people with income too high for CSR eligibility. These plans have lower out-of-pocket maximums and higher actuarial value than a regular Silver plan – they’ll save you money when you need to use your health coverage. And you can apply your premium subsidy towards their purchase price.
Cost-sharing subsidies are generally not as well understood as premium subsidies, but as long as applicants are actively comparing the nuts and bolts of each available plan – as opposed to just looking at premiums – the Silver plans that include cost-sharing subsidies will stand out as options that offer exceptional value.
They will be more expensive than Bronze plans, but will provide significantly better coverage. Their out-of-pocket maximums will be lower than that of comparably priced plans, and they will also cover more medical expenses before the out-of-pocket maximum is reached.
Gold plans: a better value in some areas
Cost-sharing reductions (CSR, aka cost-sharing subsidies) were in the headlines throughout 2017, as the Trump administration repeatedly threatened to cut off funding for them, and then announced definitively in October 2017 that the funding would end.
But despite the elimination of funding, CSR benefits continue to be available. The Congressional Budget Office estimated that the elimination of CSR funding would increase average Silver plan premiums by about 20% in 2018, and most insurers did add the cost of CSR to their premiums. In most states, the cost of CSR was added to Silver plan premiums for 2018, but some states and insurers took other approaches. For 2019 and 2020, insurers in even more states added the cost of CSR to Silver plan premiums. In nearly every state, they have continued to do so for 2021 (a budget bill enacted in late 2019 ensured that this approach could continue to be used by insurers in 2021, and it’s overwhelmingly the most common approach that insurers take). There are only three states where Silver-loading isn’t allowed (Indiana, Mississippi, and West Virginia), although West Virginia will transition to Silver loading as of 2022.
Because premium subsidies are based on the cost of Silver plans (specifically, the benchmark plan in each area), the majority of the premium increase to cover the cost of CSR is ultimately still being paid by the federal government, in the form of larger premium subsidies.
But due to the CSR funding cut, Silver plans in some areas now actually cost more than Gold plans, and some enrollees can qualify for premium-free Gold plans after their subsidy is applied. For people with income below 200% of the poverty level (about $25,520 for a single individual in 2021; note that the prior year’s poverty level numbers are used for these calculations), the best choice is probably a Silver plan for 2021, as the out-of-pocket costs are much lower due to CSR, and the ARP’s enhanced premium subsidies will offset much of the higher premiums. But people with income above 200% of the poverty level might be better off with a Gold plan instead of a Silver plan if the premiums are quite similar (CSR is available up to 250% of the poverty level, but its effects are much less significant once you exceed 200% of the poverty level).
Because the cost of CSR is now being added to Silver plan premiums in most areas, there continue to be Gold plans that are less expensive than Silver plans in some areas. Consumers should shop carefully and look at all of the available options before making a decision — don’t assume that pricing will follow the patterns we saw pre-2018, when premiums generally rose consistently from one metal level to the next.
Although premium subsidies offset the increased cost of Silver plans for most people, Silver plans are disproportionately expensive in most areas for people who aren’t eligible for premium subsidies. If they buy a Silver plan, they’re paying not only for the regular cost of the coverage, but also for the cost of CSR, since that cost is baked into the premiums for Silver plans in most areas. This is a big part of the reason Silver plan selections have dropped off since 2017; people who don’t get premium subsidies are generally better off with a plan at a different metal level.
One size does not fit all
If your household income doesn’t exceed 200% of poverty (this amounts to $43,440 for a family of three enrolling in 2021 coverage), a Silver plan with integrated cost-sharing subsidies will likely be the best choice for you, and will likely provide a better overall value than the Bronze, Gold, or Platinum plans.
This might also be true for people with income between 200 and 250% of the poverty level, but as noted above, a Gold plan might be a better value in 2021 in some areas, due to the way some states and insurers are adding the cost of CSR to premiums.
People who have moderate pre-existing conditions and expect to file claims during the upcoming year (or the remainder of 2021, if they’re enrolling during the COVID-related enrollment period) will probably be better served by a higher level plan (or a cost-sharing Silver plan if they qualify for it), regardless of premiums.
But very healthy applicants may find that they prefer the lower premiums of a Bronze plan, despite the potential for higher costs if they do need to file a claim. And enrollees with very serious medical conditions, who know they will meet their plan’s maximum out-of-pocket no matter what plan they select, might find that they’re also better off with a lower-cost Bronze plan (or an HSA-qualified plan at any metal level), since the combined total cost of the premiums and out-of-pocket exposure might end up being lower. There’s no one-size-fits-all when it comes to health coverage; each person’s health history, risk tolerance, and budget have to be taken into consideration when selecting a plan.
Personal assistance from a navigator or broker will be invaluable if you’re struggling to compare the various options available to you. (You can call one of healthinsurance.org’s partners at (866) 686-8071 to talk with a licensed, exchange-certified broker who can enroll you in an ACA-compliant plan.)
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.