Untangling Coverage Choices as Sign-Up Season Starts Under Obama Health Law

The Trump administration also stopped reimbursing insurers that reduced out-of-pocket costs for lower-income consumers; slashed financing for nonprofits that help people enroll in exchange plans; and encouraged an expansion of so-called short-term plans. Although cheaper, such plans often provide skimpy coverage and can deny it altogether based on pre-existing conditions (including pregnancy, as my colleague Robert Pear recently reported).

The plans available on HealthCare.gov and state exchanges come in four distinct metal levels — bronze, silver, gold and platinum — that vary in how costs are split with an insurer. The more precious the metal, the less you pay out of pocket for deductibles and the like.

Certain essential health benefits are legally required across levels. Bronze and silver plans require consumers to pay more out-of-pocket costs in exchange for lower premiums; gold and platinum plans have much higher premiums but cover more and typically demand less out-of-pocket spending. (Catastrophic coverage is generally available for people under 30.)

But there are many exceptions: Benchmark silver plans the second-lowest priced silver plan — will be more expensive than gold plans in at least 1,195 counties, according to an analysis by David Anderson, a health policy research associate at Duke University. This will probably be more common in the Midwest and Southeast, he said, and in the Mountain States.

This quirk emerged last year. Here’s why: Insurers must provide lower-income consumers with discounts on their out-of-pocket costs. After the administration ended reimbursements for those discounts, insurers had to raise prices. Many loaded the extra costs onto silver plans because that’s what lower-income consumers must buy to qualify for the discounts.

Consumers who earn 100 percent to 400 percent of the poverty level (up to $100,400 for a family of four) may be eligible for subsidies, in the form of tax credits, on premiums. Those who earn 100 to 250 percent of the poverty level who enroll in a silver plan may also qualify for reductions in out-of-pocket spending. That’s why lower-income consumers are almost always better off with silver plans.

People who still qualify for subsidies but earn a bit more have other factors to consider. Some may see their subsidies shrink a bit this year — that’s because prices on silver plans, which are used to calculate subsidies, have declined slightly. In some places, those subsidies may still be large enough to offset most of the monthly premium costs of, say, a bronze plan or to make a gold plan more reasonable.