Chapter 3: Looking beyond the lowest premium (The Insider's Guide to Obamacare's Open Enrollment 2016-2017)

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Chapter 3: Insider’s Guide to Obamacare’s Open Enrollment

Looking beyond the lowest premium

A health plan’s premium is only one piece of your coverage cost. Here's how to 'crunch the numbers' and see the real bottom line.

The Insider's Guide to Obamacare's Open Enrollment 2016-2017 EditionOpen enrollment for 2017 coverage begins on November 1, 2016. Now’s the time to think about what you want in your insurance coverage for the coming year. (Read about your coverage options outside of open enrollment if you have a qualifying event and if you don’t.)

For many people – especially those who are currently healthy – premium is the most important factor. But it shouldn’t be the only factor upon which you base your selection, even if your primary concern is financial (as opposed to things like provider networks, drug formularies, and quality ratings).

For many years, we’ve been helping our clients calculate the financial worst case scenario, along with the average scenario, for all the plans they’re considering.

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, be sure to use the after-subsidy premium for each plan when you’re calculating how much the coverage will cost.

The ACA’s limit on out-of-pocket maximums make this sort of financial comparison easier than it was in the past. In 2017, no ACA-compliant plan will have a maximum out-of-pocket that exceeds $7,150 for an individual or $14,300 for a family. And as was the case in 2016, all family plans will be required to have embedded individual out-of-pocket maximums. (No single individual on a family plan will be required to pay more than $7,150 in out-of-pocket costs, even if the family deductible has not yet been met.)

But some plans – especially at the Gold and Platinum level – have maximum out-of-pockets 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.

Crunch the numbers

Let’s look at a hypothetical example for Kelly, a single 35-year-old applicant who doesn’t qualify for subsidies. 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.

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 percent of total healthcare costs, respectively, their plan structure varies significantly from one policy to another, even within the same metal level. (Health insurance carriers have the option to offer standardized plans through for 2017, and some states – like California – already have standardized plans in their state-run exchanges. But by and large, it can still be challenging to make an apples-to-apples comparison of plans, even within the same metal level.)

Some plans have separate deductibles for things 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 $240/month, and has a $6,000 deductible with all claims applied to the deductible. After the deductible, Kelly would pay 40 percent of her claims until she reaches a $7,150 maximum out-of-pocket.
  • The Silver plan is $270/month, has a $3,000 deductible, and Kelly will be responsible for 30 percent of the claim after the deductible, until she reaches a $5,500 maximum out-of-pocket.
  • The Gold plan is $350/month, has a $1,000 deductible, and Kelly will pay 20 percent of her claims after the deductible until she reaches the maximum out-of-pocket of $3,000.

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: $2,880 + $7,150 = $10,030
  • Silver: $3,240 + $5,500 = $8,740
  • Gold: $4,200 + $3,000 = $7,200

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 pre-existing conditions, 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 $3,600 after the network-negotiated discount? Here’s her total expense for the year (premiums + out-of-pocket costs) with each plan:

  • Bronze: $2,880+ $3,600 (total claim applied to the deductible) = $6,480
  • Silver: $3,240 + $3,000 (deductible) + $180 (30% of the remaining $600) = $6,420
  • Gold: $4,200 + $1,000 (deductible) + $520 (20% of the remaining $2,600) = $5,720

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.

Tiered networks

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 were by far the most popular choice during the first three open enrollment periods. In 2014, 65 percent of people who enrolled through selected Silver plans, and 95 percent of those Silver plans included financial assistance. In 2015, Silver plans accounted for 69 percent of enrollees. And 71 percent of enrollees in the federally facilitated marketplace picked Silver plans for 2016, along with 59 percent of enrollees in states with their own enrollment platforms.

One reason for the popularity of Silver plans – and the high percentage of Silver plan enrollees who received premium subsidies – is cost-sharing subsidies. If your household income does not exceed 250 percent of poverty, you’re eligible for cost-sharing subsidies in addition to premium subsidies.

The cost-sharing subsidies are automatically included in Silver plans for enrollees eligible to receive cost-sharing subsidies (cost-sharing subsidies are not available at the other metal levels). 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.

One size does not fit all

If your household income doesn’t exceed 250 percent of poverty ($50,400 for a family of three during the open enrollment period that begins in November 2016), 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.

And people who have pre-existing conditions and expect to file claims during the upcoming year 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. 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’s partners at 1-844-608-2739 to talk with a licensed, exchange-certified brokers who can enroll you in an ACA-compliant plan.)