This is a follow-up from yesterday’s post on how systems need to change to address the weirdness of Silver Loading and Gold Gapping in the individual market. Today’ we’ll talk about what you should do. This only applies if you buy your insurance in the individual market.
First, let’s establish some basic guidelines for everyone:
- Health insurance is complicated and your situation is your own
- SHOP, SHOP, SHOP
- Ask for help from brokers/agents and navigators as needed
- SHOP, SHOP, SHOP
The Kaiser Family Foundation has a great set of FAQs for everybody to peruse. That should be your first stop.
The second thing to do is check to see if you are Medicaid eligible. The exchange should send you towards Medicaid if your income qualifies you. This is under $16,600 for a single person or $33,900 for a family of four.
If you are not Medicaid eligible and earn between 100% and 150% FPL ($12,060 to $18,090) go Silver. You still qualify for the reduced out of pocket expenses. The insurer has to give that to you. The entire CSR fight is a behind the scenes fight on how these costs are reimbursed to the insurer.
No Load States (North Dakota, Vermont, Washington DC)
Nothing has changed, do what you did last year.
Broad Load States (Delaware, West Virginia, Kentucky, Indiana, Oklahoma, Colorado)
All plans are more expensive. Bronze plans will be comparatively cheaper for subsidized buyers and Gold/Platinum plans will be comparatively more expensive. The benchmark Silver will cost the same for subsidized buyers and the least expensive Silver will be slightly cheaper as the gap is bigger. Off-Exchange, you’re paying more. Look around and determine what is the minimal network you need and be ready to switch insurers and plans to save some money.
Silver Load and Silver Switch States
This is where it gets confusing. In some regions of the state, the price order will be Bronze-Silver-Gold-Platinum. In those areas, follow the rules of Broad Load.
In other regions, the price order will be Bronze-Gold-Silver-Platinum. Here is where you need to pay attention.
If you make between 150% and 200% FPL ($24,120) you have some choices to make. You still qualify for good CSR but the monthly premiums will be higher than some Gold plans. Gold plans for people who qualify for mid-range CSR have higher deductibles but may have lower premiums. If you see a Silver plan and a Gold plan with an insurer and network that you like, you have to make a choice. Do you trade a bigger monthly payment for a smaller out of pocket maximum. For people who think that they are likely to be healthy and have some assets to absorb a financial hit, this trade for Gold may make sense. For people who know that they will hit the out of pocket max no matter what, staying with Silver is probably a good idea.
In the Silver Load and Silver Switch states, the complexity really starts to happen. We’ll work through Pennsylvania’s Silver Switch loading below the fold:
Not every county in Pennsylvania has a Gold Gap. The counties that don’t have a Gold Gap are the counties where one company decided to Broad Load and everyone else decided to Silver Load. This makes the Gold plan just slightly more expensive than the benchmark Silver. In those counties people have to make the decision as to whether or not paying a little more for Gold per month is worth buying the much lower out of pocket expenses. In most cases in Pennsylvania it will be as most counties the extra premium for Gold is less than $25 per month for a single individual. $300 a year to avoid several thousand dollars in out of pocket expenses is a reasonable trade for many people. However there are counties like Franklin and Lancaster where Gold is priced significantly above Silver so this is not an automatic case.
In most counties in Pennsylvania including the two largest, Philadelphia and Allegheny, Gold is less expensive then the Benchmark Silver. In Allegheny County, the choice is simple, the least expensive Gold plan is from my former employer, UPMC Health Plan. It is on the same network (Partners) as the benchmark Silver and they are both EPOs. The Gold plan in this case dominates the benchmark Silver as it is the same network with lower out of pocket costs and lower premiums. In Allegheny County anyone who makes between 200% and 400% FPL should not buy Silver if they are only shopping on price.
Greater Philadelphia is more complicated. There is a Gold plan $1 less than the benchmark Silver. There is also a Silver plan $102 less than the Benchmark Silver for a 21 year old (for a 64 year old that plan is $306 less than the Benchmark). The challenge is figuring out if the extra premiums for a Gold plan are worth the lower out of pocket hit. For people who know that they are likely to max-out, Gold is probably worth it if the network is sufficient. For people who think that they will be pretty healthy, Silver in Philadelphia is still a decent choice.
So yeah, this is complicated. In regions where there is only a single insurer, it is simpler when there is Silver Loading. In regions with multiple insurers making multiple choices, there will be a good deal available compared to last year but there are no hard and fast decision rules.