How ACA Marketplace Premiums Are Changing by County in 2021

Premiums for ACA Marketplace benchmark silver plans are decreasing on average across the U.S. in 2021 for the third consecutive year. However, premium changes vary widely by location and by metal level, with premiums increasing in several cases. As most enrollees receive significant premium subsidies on the exchange markets, the net premium amount an exchange enrollee pays out-of-pocket depends on their income and the difference in the cost between the benchmark plan (second-lowest silver plan) and the premium for the plan they choose.

ACA premiums are falling in many areas of the U.S in 2021. This analysis has interactive maps with county-level data illustrating changes for the lowest-cost bronze, silver & gold plans across the country.

In this analysis, we collect and analyze data from rate filings insurers submit to state regulators, state exchange websites, and healthcare.gov to see how premiums are changing at the county level both before and after subsidies in 2021. In an earlier analysis of insurer rate filings, we found that, while insurers expressed uncertainty about the effect of the pandemic on their costs for next year, many insurers decided not to factor in any premium increase attributable to COVID-19. As we show in this analysis, premiums are falling on average, but actual payments vary greatly depending on location and income. We find that “free” ($0 premium) bronze plans are available in 84% of counties to the lowest-income subsidized Marketplace enrollees. Because insurers load additional costs onto silver plans, we also find that in 983 counties, gold premiums are lower than or comparable to the cost of silver plans.

The map below illustrates changes in premiums for the lowest-cost bronze, silver, and gold plans by county. Results are shown for a 40-year-old paying the full premium and for a 40-year old with an income ranging between $20,000 (roughly 160% of poverty) and $40,000 (roughly 310% of poverty), who would be eligible for a premium tax credit.

Figure 11

Nationally, the average benchmark silver premium – on which subsidies are calculated – is decreasing by about 2.2% (Table 1). Meanwhile, the unsubsidized premium for the lowest-cost bronze and lowest-cost silver plans are decreasing by an average of roughly 1 percentage point and the lowest-cost gold plan premiums are dropping by an average of about 4%.

Table 1: Change in the Average Lowest-Cost Premium by Metal Level Before Tax Credit, 2020-2021 for a 40-year-old 
  2020 2021 % Change
Lowest Cost Bronze Premium  $331 $328 -0.9%
Lowest Cost Silver Premium  $442 $436 -1.4%
Lowest Cost Gold Premium  $501 $481 -4.0%
Benchmark Premium  $462 $452 -2.2%
SOURCE: KFF analysis of premium data from Healthcare.gov and review of state rate filings.

On one hand, the benchmark premium is dropping by more than the lowest-cost silver and bronze plans, which could mean the tax credit covers somewhat less of the premium for subsidized enrollees who enroll in these lower-cost plans this year. On the other hand, lowest-cost gold premiums are dropping at a faster rate than benchmark premiums, meaning that the tax credit may cover a larger share of the premium, on average, for people buying gold plans. In either case, premium changes vary by geography as shown in the map above, so whether enrollees will see their premiums increase or decrease for 2021 will depend on how benchmark premiums are changing and how premiums for plans at their preferred metal level are changing in their county. For example:

  • In Mayes County, Oklahoma, for example, unsubsidized premiums for benchmark silver plans are decreasing by 35%, while unsubsidized premiums for lowest-cost bronze plans are virtually flat. This means that premium tax credits will decrease based on the benchmark silver plan premium, but since the lowest-cost bronze plan premiums in 2021 are similar to 2020, subsidized enrollees’ net bronze premiums (after tax credits) will increase.
  • Conversely, in Cameron County, Pennsylvania, unsubsidized benchmark silver premiums are increasing by 17% while lowest-cost bronze plans are decreasing by 15%. In areas like this, where the gap between the benchmark plan and the lowest-cost bronze premium is growing, premium tax credits will cover more of the total premium for a low-cost bronze plan in 2021 and bronze premium payments (after tax credits) will go down for subsidized enrollees.

Table 2 provides examples of average net premiums for Marketplace enrollees with certain income an age combinations, after accounting for tax credits.

Table 2: Change in the Average Lowest-Cost Premium by Metal Level After Tax Credit, 2020-2021
40-year-old with $20,000 income (157% of poverty) 2020 2021 % Change
   Lowest Cost Bronze Premium $2 $2
   Lowest Cost Silver Premium $60 $62 3.2%
   Lowest Cost Gold Premium $118 $105 -10.9%
40-year-old with $25,000 income (196% of poverty)
   Lowest Cost Bronze Premium $25 $24 -3.3%
   Lowest Cost Silver Premium $117 $118 0.6%
   Lowest Cost Gold Premium $177 $163 -7.7%
40-year-old with $30,000 income (235% of poverty)
   Lowest Cost Bronze Premium $75 $76 1.1%
   Lowest Cost Silver Premium $180 $180
   Lowest Cost Gold Premium $239 $226 -5.6%
40-year-old with $35,000 income (274% of poverty)
   Lowest Cost Bronze Premium $140 $143 1.9%
   Lowest Cost Silver Premium $249 $250 -0.3%
   Lowest Cost Gold Premium $308 $295 -4.4%
40-year-old with $40,000 income (313% of poverty)
   Lowest Cost Bronze Premium $197 $205 4.4%
   Lowest Cost Silver Premium $307 $313 2.0%
   Lowest Cost Gold Premium $366 $358 -2.2%
 SOURCE: KFF analysis of premium data from Healthcare.gov and review of state rate filings.

As has been the case since 2018, insurers generally load the cost from the termination of federal cost-sharing reduction payments entirely onto the silver tier (a practice sometimes called “silver loading”). The relatively higher price for silver plans due to silver loading means subsidy-eligible Marketplace enrollees will continue to receive relatively large premium tax credits, although the dollar amount may be somewhat smaller than in past years based on decreases in the underlying benchmark silver premiums. Subsidies calculated based on silver-loaded premiums continue to make gold and bronze plans less expensive (or even $0 in some cases) compared to before cost-sharing reduction payments were terminated. Subsidized premiums for bronze plans may be particularly attractive to many people eligible for premium tax credits (Table 3). For example, the tax credit for a 40-year-old individual making $20,000 covers the full cost of the premium for the lowest-cost bronze plan in 84% of counties (2,635 out of 3,141 counties in the U.S.). This is similar to 2020, when the tax credit has covered the full cost of the lowest-cost bronze plan for a low-income enrollee in 85% of counties (2,661 counties).

Table 3: Number of Counties Where an Individual’s Tax Credit Covers the Full Premium of the Lowest-Cost Bronze Plan, for a 40-year-old
Example Age and Income 2020 2021
40-year-old with $20,000 income 2,661 (85% of counties) 2,635 (84% of counties)
40-year-old with $25,000 income 1,736 (55%) 1,585 (50%)
40-year-old with $30,000 income 608 (19%) 535 (17%)
40-year-old with $35,000 income 287 (9%) 263 (8%)
40-year old with $40,000 income 135 (4%) 45 (1%)
SOURCE: KFF analysis of premium data from Healthcare.gov and review of state rate filings.

However, even if subsidized silver premiums are higher than subsidized bronze premiums, it is still important for low-income enrollees to consider the significant cost-sharing assistance that is only available if they enroll in a silver plan. In order to qualify for a plan with a cost-sharing reduction (CSR), low-income enrollees must sign up for a silver plan. CSR plans lower the amount an enrollee spends out-of-pocket by setting a lower out-of-pocket maximum, which also translates to lower deductibles, copayments, and coinsurance. For example, a single individual making between 100-200% of the poverty level can qualify for a silver plan with an out-of-pocket maximum of no more than $2,850, and the deductible would be significantly lower than that. If the same individual instead signs up for a bronze plan, the out-of-pocket maximum and deductible could be up to $8,550. If this person is sick or expects to have high health spending, it may be better to pay a relatively higher premium for a silver plan even if a bronze plan is available for a $0 premium.

The map below shows where an individual’s tax credit covers the full premium of the lowest-cost bronze plan for a 40-year-old with an income between $20,000 (157% of poverty) to $40,000 (313% of poverty).

Figure 2

For subsidized enrollees, a gold plan may actually be available at no cost after tax credits are applied as well. For example, the tax credit for a 40-year-old individual making $20,000 covers the full cost of the premium for the lowest-cost gold plan in 188 counties (out of 3,141 counties in the U.S.). This is a decrease from 2020, when the tax credit covered the full cost of the lowest-cost gold plan in 249 counties.

Additionally, as shown in the tables and figures above, the average cost of gold plans across the country are decreasing more on average than bronze or silver plans heading into 2021. In many counties, the lowest cost gold plan available is in fact cheaper than the lowest cost silver plan available, a product of silver loading discussed earlier.

For 2021, enrollees in 670 counties will be able to choose a gold plan that is cheaper than the lowest cost silver plan available in their area. This compares to just 465 counties where the lowest cost gold plan was cheaper than the lowest cost silver plan in 2020. The map below shows the 983 counties where the unsubsidized premium for the lowest-cost gold plan either has a lower or comparable (within $10) premium to the lowest-cost silver plan in 2021, before tax credits are applied.

Figure 3

In 2021, enrollees in roughly 1 out of 5 counties will be able to choose from a gold plan with a cheaper monthly premium than the lowest cost silver plan offered in their area. The increasing availability of lower cost gold plans is favorable for consumers in these areas, since gold plans have lower cost sharing (deductibles, copayments, and coinsurance), and offer more financial protection plans in lower metal levels. However, Marketplace enrollees are very price-sensitive and only about 8% of enrollees sign up for a gold plan.

Discussion

Although the sticker prices for many ACA Marketplace plans are dropping, what a given consumer actually pays depends on their income, location, and differences in pricing between their selected plan and the benchmark silver plan. For consumers to know how much they will pay net of subsidies, they must return to Healthcare.gov or their state’s exchange each year and carefully consider their options.

Since premiums for benchmark silver plans in 2021 continue to be higher than those of bronze plans, low-income enrollees in many parts of the country qualify for “free” (zero-premium) bronze plans. The benchmark (second-lowest cost) silver plan is the basis for determining the amount of financial assistance consumers receive. When benchmark premiums are high in comparison to bronze plans, the large tax credit may cover all or most of the cost of a bronze plan. While “free” bronze plans will be available to subsidized enrollees in many counties in 2021, it is still important for low-income enrollees to consider the significant cost-sharing assistance that is only available if they enroll in a silver plan. Marketplace enrollees eligible for cost-sharing subsidies are often best off paying a premium each month for a silver plan, in order to reduce their out-of-pocket costs when they need medical care. Nonetheless, low-income people eligible for subsidies are certainly better off signing up for a free bronze plan than they would be by going without insurance. This is the case in any year, but particularly so now given the ongoing pandemic.

Methods

We analyzed data from the 2020 and 2021 Individual Market Medical files to determine premiums and the benchmark amounts to calculate premium tax credits for the scenarios presented. These files are available at data.healthcare.gov. Premiums for the 15 state-based marketplaces are from a review of insurer rate filings and state plan finders. For most states running their own exchange, premiums presented in this analysis are at the rating area level. Premiums for California and Massachusetts were collected at the zip code level, and premiums for Washington, Nevada, and Pennsylvania were collected at the county level. All premiums are displayed as the full price, rather than just the portion that covers essential health benefits.

The average changes in plan costs were weighted by county using 2020 plan selections obtained from the 2020 Marketplace Open Enrollment Period County-Level Public Use file provided by CMS, available here. In states running their own exchanges, we gathered county-level plan selection data where possible and otherwise estimated county plan selections based on the county population in the 2010 Census and total state plan selections in the 2020 OEP State-Level Public Use File provided by CMS, available here.

Endnotes
  1. The map legend shows premium changes in dollars rather than the percent change because, at the county level, percent changes may appear to overstate premium increases and understate decreases, particularly for those who qualify for relatively large premium subsidies. For example, a change from $60 to $2 is a -97% change but a change from $2 to $60 is a +2900% change. This issue is less prevalent when calculating the percent change in national average premiums, since outlier premiums are not given as much weight. The percent change in premiums by county can be viewed by hovering over the map.

     

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