How do premium changes for 2020 differ for people who get subsidies versus those who don’t?


Q. I’m seeing a lot of differing headlines about health insurance rates for 2020 — some say rates are going up, some say they’re going down… Can you shed some light on this? Do these rate changes apply to everyone?

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A. The vast majority of Americans get their health insurance either from an employer or from the government (Medicare, Medicaid, CHIP, TRICARE, VA, IHS). The rate changes that have been making headlines each fall for the last few years are for the individual market, which only accounts for about 4.2 percent of the population.

Employer-sponsored or government coverage

If you get your health insurance through your employer or from the government, the subsidies, exchanges, and the individual market health insurance rates that you’re seeing in media reports don’t apply to you.

Employer-sponsored insurance rates change annually, and your employer will provide you with information related to your plan options for the coming year, including how your plan, premiums and/or cost-sharing might be changing.

If you have Medicare, Medicaid, or CHIP coverage, you’ll receive information from the government or from your private insurer (if you’re enrolled in a Medicare Advantage, Medigap, Medicare Part D, or Medicaid/CHIP managed care plan), letting you know how your coverage and/or costs might be changing for the coming year.

Pre-ACA individual/family plans

If your health insurance plan is grandfathered or grandmothered, you’re in a separate risk pool from the ACA-compliant plans offered by your health insurer, which means your rate increases for 2020 won’t match the rate increases you might be seeing in media reports about ACA-compliant plans issued by your insurance company. [There’s no requirement that carriers continue to renew grandfathered and grandmothered plans — they can decide to cancel them instead, and replace them with ACA-compliant plans.]

ACA-compliant individual/family plans

If you have an individual/family major medical health insurance plan, purchased on-exchange or off-exchange, that became effective January 2014 or later, it’s compliant with the ACA. The annual rate changes for these plans have been making headlines for the last few years, but the actual rate changes that apply to each enrollee’s premiums differ significantly because there are so many factors involved. Here are some things to keep in mind:

  • When you see headlines about rate changes, they almost always apply to full-price premiums, before any premium subsidies are applied. But 87 percent of the people who get their coverage via the exchanges are receiving premium subsidies (and the majority of the entire individual market population has coverage via the exchanges). These subsidies make a huge difference in terms of how much people actually pay for their coverage and how much their after-subsidy premiums change from one year to the next.
  • Average full-price premiums increased significantly in 2017 and 2018. But they increased by less than 3 percent in 2019, and are decreasing slightly for 2020. But that’s doesn’t mean they’re decreasing slightly everywhere: It ranges from about a 20 percent decrease in Delaware and Colorado to more than a 10 percent increase in Vermont and Indiana.
  • CMS put out a press release in October 2019, noting that premiums in the exchanges were dropping by an average of 4 percent for 2020. This was widely reported in the media, but this 4 percent average rate decrease only applies to the average benchmark plans (second-lowest-cost silver plan) available via HealthCare.gov. That means it doesn’t apply to the vast majority of plans sold on HealthCare.gov, and it doesn’t apply to any of the plans sold in the 13 fully state-run exchanges.
  • You might have seen articles about very stable overall rates for 2020. Or about significant rate increases in places like Indiana and Vermont. Or like about significant rate decreases in Colorado. Or significant rate increases in Colorado. It’s no wonder people are confused. How can rates be simultaneously dropping and spiking in the same area?
  • The biggest factor is whether or not you get premium subsidies. If you don’t get a subsidy (which is the case for 13 percent of exchange enrollees nationwide, plus everyone enrolled in off-exchange plans), your rate changes are pretty straightforward and just depend on how much your insurer is changing the premium for your plan next year. Of course, you also have the option to shop around during open enrollment and select a different plan with a different premium.
  • But if you do get a subsidy, your rate change depends on multiple factors: How much your plan’s price is changing, how much your area’s benchmark plan price is changing (keeping in mind that it might not be the same plan that occupied the benchmark spot this year), as well as things like changes in your income and family size.
  • Because average benchmark premiums are decreasing for 2020, average premium subsidies are going to be smaller in 2020 than they were in 2019 (that doesn’t mean your subsidy will be smaller, since there’s a lot of variation from one area to another). And because the average decreases in benchmark premiums are more significant than overall average rate decreases, people who get premium subsidies could end up seeing a small overall average increase in their premiums in 2020, assuming they’re not already enrolled in the benchmark plan and planning to continue to have coverage under the benchmark plan.
  • If you’re in an area where the benchmark premium is decreasing significantly, you could find that your after-subsidy premium ends up increasing significantly, which can be disconcerting after you’ve seen headlines about substantial rate decreases. This is what’s happening in some parts of Colorado, for example. And it can also happen in areas where a new insurer moves into the area and undercuts the previous benchmark plan; there are at least 19 states with new insurers for 2020 and numerous other states where existing insurers are expanding their coverage areas.
  • No matter what, you need to carefully compare your options during open enrollment.
    • If you’re eligible for a premium subsidy, you need to shop in the exchange in your state. [Use our calculator to get an idea of whether you’re subsidy-eligible — it only takes a minute to find out. And make sure you understand what counts as income under the ACA and how you might be able to adjust yours to make yourself eligible for a subsidy.]
    • If you currently have a plan you purchased outside the exchange, be sure to double-check your on-exchange options for 2020 before deciding whether to renew your off-exchange plan. And keep in mind that as the poverty level numbers increase each year, the limits for subsidy eligibility go up as well. In 2014, a family of four had to have a household income of no more than $94,200 in order to get a subsidy. For 2020, that’s grown to $103,000.
    • If you have a grandmothered or grandfathered plan and your insurer is letting you renew it, be sure to carefully compare it with the ACA-compliant options that are available to you. Consider the benefits as well as the premiums.

So the answer to your question about rates is… it depends. It depends on where you live, what plan you have, and whether you get a premium subsidy. And if you do get a subsidy, there are several variables that go into how much your rates might be changing. So ignore the headlines. Focus on the plans that are available to you and see how your premium and out-of-pocket costs might change if you select a different plan versus keeping the one you have.

Thanks to the ACA, you have the option to shop from among all of the available plans in your area each year, regardless of whether you have health conditions or not (prior to the ACA, people in most states had limited access to new health plans in the individual market if they had pre-existing conditions).

The initial transition to ACA-compliant plans

The ACA makes health insurance available to anyone who applies (no more underwriting rejections or rate-ups) and subsidizes the cost for people who need it the most.

Some people who don’t get a premium subsidy saw sharp rate increases in 2014, with the transition to a guaranteed-issue market and plans that cover the essential health benefits. But even among people who pay full-price for their coverage, some enrollees may have experienced a rate decrease when they switched to an ACA-compliant plan, even without a subsidy. That could be the case for a variety of populations:

  • If they already opted for a very comprehensive, low-deductible plan prior to 2014, they may have been able to find coverage in the exchanges that wasn’t significantly more expensive than what they paid prior to 2014.
  • If they had an underwriting rate-up on their pre-2014 plan, the new plans might have been a less-expensive alternative. Although the standard rates for ACA-compliant plans were higher than the pre-2014 base rates, there’s no additional charge for people with pre-existing conditions. Prior to 2014, that was not the case. People with pre-existing conditions were often charged rates that were at least 25 percent higher than the base rates, and sometimes 100 percent higher.
  • Older applicants get a better deal than they used to prior to 2014. Rates for older enrollees are limited to three times the rates for young enrollees under the ACA, which is a dramatic shift from the pre-ACA ratios that often ran as high as five to seven times as much for an older applicant.

To summarize, there are some people who are paying quite a bit more for their health insurance now that the ACA has been implemented: primarily enrollees who are younger, healthy, had plans with high out-of-pocket exposure prior to 2014 (potentially higher than the ACA now allows, like a $10,000 individual deductible, for example), and also have incomes high enough to make them ineligible for subsidies. However, there are plenty of people who are ineligible for subsidies who don’t fall into those other categories. For them, there hasn’t been as much in the way of “rate shock” over the last few years, and they might have ended up with a better deal starting in 2014, even without accounting for subsidies.


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.

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