How ACA Marketplace Premiums Are Changing by County in 2022

Premiums for ACA Marketplace benchmark silver plans are decreasing on average across the U.S. in 2022 for the fourth 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 ACA Marketplaces, 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.

The American Rescue Plan Act (ARPA) increased and expanded subsidies temporarily for 2021 and 2022 for low- and middle-income individuals and families to purchase health coverage on the ACA Marketplaces. For 2021, some states automatically applied the increased subsidies whereas other states and HealthCare.gov for a period required enrollees to re-select a plan to get additional ARPA subsidies. Many enrollees will get the additional ARPA subsidies when filing taxes for 2021. The additional ARPA subsidies will expire at the end of 2022, but Congress is considering extending them through 2025 as part of the Build Back Better Act.

ACA premiums are falling in many areas of the U.S in 2022. This analysis has an interactive map with county-level data illustrating changes for the lowest-cost bronze, silver & gold plans across the country.

In this analysis, we 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 2022. In an earlier analysis of insurer rate filings, we found that health services spending remained below projected levels through the middle of 2021 and most insurers do not expect COVID-19 to affect their 2022 costs. We published state-level data on average 2022 Marketplace premiums at each metal level here.

As we show in this analysis, unsubsidized premiums are holding flat or falling on average nationally across metal levels, but actual payments net of subsidies vary greatly depending on location and income. After taking into account subsidies next year, many subsidized enrollees may find their premium payments for low-cost bronze plans are actually higher than this year, while payments net of subsidies for silver plans are similar and for gold plans are lower than this year.

Due to the American Rescue Plan Act (ARPA), Marketplace enrollees with incomes between 100-150% of poverty are eligible for free ($0 premium) or nearly free (requiring a nominal payment of less than $1 to $4 per month to cover non-essential benefits) silver plans. We find that free or nearly free silver plans are also available in 66% of counties to 40-year-old Marketplace enrollees with incomes of $20,000 (155% of poverty). These low-income enrollees also qualify for additional cost-sharing subsidies in silver metal level plans. Though most of them could also get a free ($0 premium) bronze plan, paying a small premium (e.g., $1 per month) for silver over bronze plans would substantially lower their deductible and other out-of-pocket cost-sharing payments.

2022 ACA Premium and Subsidy Changes

With the ARPA’s enhanced financial assistance for ACA Marketplace coverage, subsidized enrollees with incomes below 150% of poverty ($19,320 for an individual and $39,750 for a family of 4) can get a free ($0 premium) or nearly free silver plan with a very low deductible. Because financial assistance only covers the “essential health benefits” portion of the premium, enrollees with incomes below 150% of poverty may have to pay a nominal amount (e.g., $0.50 or $1 per month) for health coverage in counties where the lowest-cost silver plan and the second-lowest cost silver plan include non-EHB benefits (for example, dental or vision coverage for adults or non-Hyde abortion coverage).

In this analysis, we do not add in the non-EHB portion of premiums because that is not possible in all states with available data Therefore net premiums after subsidies may be higher in some counties. In 2022, 311 of 2,143 (12.7%) counties in HealthCare.gov states have non-EHB benefits in the lowest-cost silver and benchmark silver plans. The non-EHB portion of lowest-cost silver plan premiums (which tax credits would not cover) in these counties range from $0.04 to $4.34 per month with half counties falling between $0.04 to $2.36 per month for a 40-year-old.

The map below illustrates changes in premiums for the lowest-cost bronze, silver, and gold plans by county. (For data at the state-level, see our state tables here). 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. The ARPA’s enhanced subsidies are included for 2021 and 2022 estimates of premiums after a tax credit.

Figure 1

Nationally, the average benchmark silver premium – on which subsidies are calculated – is decreasing by about 2.4% (Table 1). Meanwhile, average unsubsidized premiums for lowest-cost bronze plans are holding flat (0.3% change), and lowest-cost silver and lowest-cost gold plan premiums are decreasing by an average of 1.8% and 4.1%, respectively.

Because benchmark premiums are dropping on average while lowest-cost bronze premiums are holding flat, 2022 subsidies will cover a somewhat smaller share of bronze premiums than they did in 2021. However, 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 2022 will depend on how benchmark premiums are changing and how premiums for plans at their preferred metal level are changing in their county.

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

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.

For low-income individuals, the tax credit may cover the full premium of the lowest-cost silver plan, which also has significantly lower deductibles (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 silver plan in 66% of counties (2,087 of 3,143 counties) in 2022. This is slightly lower than in 2021, when the tax credit for a 40-year-old individual making $20,000 covered the full cost of the lowest-cost silver plan premium in 72% of counties (2,261).

Subsidized bronze plans may be particularly attractive to people eligible for premium tax credits but not eligible for cost-sharing subsidies. For example, the tax credit for a 40-year-old individual making $35,000 (272% of poverty) covers the full cost of the premium for the lowest-cost bronze plan in 34% of counties.

In order to qualify for a plan with a cost-sharing reduction (CSR), low-income enrollees must sign up for a silver plan. CSR in silver plans lowers the amount an enrollee spends out-of-pocket by setting a lower out-of-pocket cost-sharing 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 $2,900, 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 $8,700. People with incomes under 200% of poverty who are eligible for significant assistance with cost-sharing are often eligible for silver plans with no monthly payment. Even if they do have a small payment each month, they are often better off paying a small monthly premium for a silver plan even if a bronze plan is available for a $0 premium.

We also find that a 40-year-old Marketplace enrollee making $30,000 per year (233% of poverty) would be eligible for a free bronze plan in 79% of counties, and those with incomes of $35,000 (272% of poverty) would be eligible for a free bronze plan in 34% of counties. Enrollees at these incomes are eligible for little or no financial aid to lower deductibles and therefore may find a free bronze plan to be an attractive option.

Discussion

Although the sticker prices for many ACA Marketplace plans are dropping, what a given person actually pays depends on their income, location, and differences in pricing between their selected plan and the benchmark silver plan. For people 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.

Because of ARPA subsidies, enrollees with incomes between 100% and 150% of poverty qualify for free or nearly-free benchmark and lowest-cost silver plans with substantially reduced out-of-pocket costs. Enrollees with incomes over 150% of poverty in many parts of the country can similarly qualify for free (zero-premium) or nearly free (requiring a nominal payment to cover non-essential benefits) silver and bronze plans. The benchmark (second-lowest cost) silver plan is the basis for determining the amount of financial assistance people receive. The large tax credit may cover all or most of the cost of the lowest-cost silver or several bronze plans.

While free bronze plans will be available to subsidized enrollees in many counties in 2022, 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 in a silver plan, which will reduce their out-of-pocket costs when they need medical care.

Methods

We analyzed data from the 2021 and 2022 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 state-based marketplaces are from a review of insurer rate filings and state plan finders. Premiums for California and Massachusetts were collected at the zip code level, and premiums for the District of Columbia, Idaho, Maine, Minnesota, New Mexico, New Jersey, New York, Nevada, Pennsylvania, and Washington, were collected at the county level. For the other states running their own exchange, premiums presented in this analysis are at the rating area level. ACA financial assistance only covers the “essential health benefits” portion of the premium. Enrollees must pay for any non-essential benefits. However, we do not add in the non-essential portion of the premium because that is not possible in all states with available data. Therefore, premium payments after subsidies may be higher than the amount in this analysis.

The average changes in plan costs were weighted by county using 2021 plan selections obtained from the 2021 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.

Appendix

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