How ACA Marketplace Premiums Are Changing by County in 2023
Premiums for ACA Marketplace benchmark silver plans are increasing on average across the U.S. in 2023 after four years of slight declines. However, premium changes vary by location and by metal level, with premiums decreasing in some cases. As most enrollees receive significant premium subsidies on the ACA Marketplaces, the net premium amount an exchange enrollee pays depends on their income and the difference in the cost between the benchmark plan (second-lowest-cost silver plan) and the premium for the plan they choose.
In this analysis, we use data from rate filings insurers submit to state regulators, state exchanges, insurance departments, and HealthCare.gov to see how premiums are changing. In an earlier analysis of insurer rate filings, we found that premium growth is primarily attributed to rising prices for health care services and a rebound in utilization (which had been lower than usual earlier in the pandemic). We published state-level data on average 2023 Marketplace premiums at each metal level here.
2023 ACA Premium and Subsidy Changes
As we show in this analysis, unsubsidized premiums are increasing 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, silver, and gold plans are lower in 2023.
Due to the Inflation Reduction Act, Marketplace enrollees with incomes between 100-150% of poverty are eligible for free ($0 premium) or nearly free (requiring a nominal payment to cover non-essential benefits) silver plans. These low-income enrollees also qualify for additional cost-sharing subsidies, meaning they can find plans with very low deductibles, but only if they enroll in a silver plan. Though most low-income enrollees could also get a free ($0 premium) bronze plan, opting for silver plans substantially lowers their deductible and other out-of-pocket cost-sharing payments.
Nationally, the average benchmark silver premium – on which subsidies are calculated – is increasing by 4.1% (Table 1). Meanwhile, average unsubsidized premiums for lowest-cost bronze plans are increasing (4.0% change), and lowest-cost silver and lowest-cost gold plan premiums are increasing by an average of 4.7% and 2.2%, respectively.
The vast majority of enrollees are subsidized and therefore will not necessarily pay these increases. With the enhanced financial assistance for ACA Marketplace coverage provided by the Inflation Reduction Act, subsidized enrollees with incomes at or below 150% of poverty ($20,385 for an individual and $41,625 for a family of 4) can get a free ($0 premium) or nearly free silver plan with a very low deductible if they sign up for the lowest or second-lowest cost silver plan. Relative to the original ACA subsidies, the Inflation Reduction Act also reduced payments for middle-income enrollees and removed the upper income limit on subsidy eligibility.
Because financial assistance only covers the “essential health benefits” (EHB) portion of the premium, enrollees with incomes between 100% to 150% of poverty may have to pay a nominal amount (e.g., $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 adjust for the non-EHB portion of premiums because that is not possible in all states with available data. Therefore, net premiums after subsidies may differ in some counties.
The map above 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 (147% of poverty for 2023 enrollees) and $40,000 (294% of poverty), who would be eligible for a premium tax credit. Enhanced subsidies under the ARPA and IRA are included for 2022 and 2023 estimates of premiums after a tax credit, respectively.
Because benchmark premiums are increasing at a higher rate than premiums for lowest-cost bronze and gold plans, 2023 subsidies will generally cover a larger share of bronze and gold premiums than they did in 2022, on average. The portion of premiums covered by subsidies varies by county depending on how local premiums are changing. Whether enrollees see their premiums increase or decrease for 2023 depends on how benchmark premiums and 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 metal-level combinations, after accounting for tax credits.
Although the sticker prices for many ACA Marketplace plans are increasing, what a given person 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 Inflation Reduction Act subsidies, enrollees with incomes between 100% and 150% of poverty qualify for free (zero-dollar premium) or nearly free (requiring a nominal payment to cover non-essential benefits) benchmark and lowest-cost silver plans with substantially reduced out-of-pocket costs. Many enrollees with incomes over 150% of poverty can similarly qualify for free or nearly free lowest-cost silver and bronze plans, depending on their geographic area.
While free bronze plans will be available to subsidized enrollees in many counties in 2023, 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.
We analyzed Marketplace premiums data for 2022 and 2023 to determine premiums and the benchmark amounts to calculate premiums, tax credits, and net premiums after tax credits for the scenarios presented. Federal Marketplace files are available through HealthCare.gov. Premiums for state-based marketplaces are from a review of insurer rate filings, state plan finders, or data provided directly by state exchanges or insurance departments. Premiums for California and Massachusetts were collected at the zip code level; premiums for Colorado, Connecticut, Idaho, Maine, Minnesota, New Jersey, Nevada, New York, and Washington were collected at the county level; and premiums for Maryland and Pennsylvania were collected at the county or zip level depending on whether premiums are uniform throughout the county. For the remaining states running their own exchanges, premiums presented in this analysis were collected 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, since we do not adjust for the non-essential portion of the premium, premium payments after subsidies may differ from the amount in this analysis.
Calculation of the national average changes in plan costs were weighted by county using 2022 plan selections obtained from the 2022 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 or we estimated county-level plan selections by determining the share of plan selections by county for a given state in a prior year and applying this to the total state plan selection value from the CMS 2022 OEP State-Level Public Use File, available here.