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If all Silver plans cover the same benefits and percentage of costs, why do premiums vary by carrier?

  • August 10, 2016

Q. If all of the Silver plans in an exchange must offer the same benefits, and cover 70 percent of the cost of those benefits, why do premiums vary from carrier to carrier?

A. First, it’s important to understand that the benefits offered by plans at the same metal level can vary significantly from one plan to another. All plans must include the ten essential benefits (although pediatric dental works a bit differently from the other nine). But they can provide that coverage with very different specifics for the benefits.

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In order to be designated Silver, a plan’s actuarial value (AV) must be between 68 and 72 percent. That indicates the percentage of average costs that the plan will cover – but that’s across the entire enrolled population.

A person who is very healthy and uses very little in services might end up paying the bulk of her own expenses during the year, via copays and her deductible. On the other hand, a person with a serious health condition might end up with 99 percent of her costs covered by the plan, since her deductible and maximum out-of-pocket might pale in comparison with the amount that the insurer pays after the out-of-pocket maximum is met.

The other metal levels have AVs in the range of 60 percent (Bronze), 80 percent (Gold), and 90 percent (Platinum). But carriers can structure their plans however they like, as long as they conform to the AV requirements and any other applicable mandates – like the inclusion of essential health benefits, for example.

Secondly, prices will vary by location. Even within a state, healthcare may well be more expensive in one city than in another, depending on cost-of-living and what doctors and hospitals in that town charge.

Third, some plans may offer “extras” above and beyond the 10 essential benefits.

Fourth, and most importantly, different plans will use different networks of doctors and hospitals who agree to provide care to their customers at a certain price.

But some doctors and hospitals charge far more than others, even for simple procedures,  and they may refuse to negotiate with insurers.  These providers are not necessarily better, but they have a brand name that lets them command higher prices.

If the carrier wants to keep premiums down, it may well exclude some very expensive providers from its network. Thus, less expensive silver plans are likely to offer access to a narrower network.

Insurers know that when customers shop in the exchanges they will be checking to see which hospitals and doctors are included. If the network is too narrow, the carrier could lose market share.

At the same time, polls show that younger consumers (aged 18 to 34 years) are three times as likely to be willing to give up their choice of doctor for a lower health insurance cost.  And  those healthy 18- to 34-year-olds are precisely the customers insurers want.