Age, county, tobacco use and household composition set the price. Health history cannot. Your credit is applied before you pay.
Four inputs, nothing else
Marketplace premiums are community rated. A carrier files one price per plan per rating area, then adjusts it only for age, tobacco use and the number of people on the policy. Two people the same age in the same county pay the same base rate for the same plan, regardless of medical history.
This is why a quote needs a ZIP code before it can show a real number. Rating areas are county based, and the same plan can differ by hundreds of dollars across a state line.
Age curves and family pricing
The federal age curve caps the oldest adult rate at three times the youngest adult rate. Children under 15 are rated at one flat factor, and only the three oldest children under 21 are charged on a family policy.
That is why an accurate quote asks for each person's date of birth rather than a household average. An estimate priced at a single age is directional, not final.
How the premium tax credit is applied
The advance premium tax credit is calculated from your expected annual household income and the price of the second lowest cost silver plan in your county, called the benchmark plan. The credit is the gap between that benchmark price and the share of income you are expected to contribute.
The credit is a fixed dollar amount, so it can be applied to any metal level. Applying it to a cheaper bronze plan often takes the monthly premium to zero, and applying it to a richer gold plan narrows the gap that gold usually carries.
What changes your premium mid year
The plan rate itself is locked for the plan year. What changes is your credit, and it changes when the facts behind it change.
- A raise, a job loss or a change in self employment income
- Someone joining or leaving the household
- A move to a different county or state
- Gaining access to affordable employer coverage
Common questions
Key facts
Sources
- HealthSherpa quoting API, plan rates by rating area
- CMS Marketplace eligibility API, benchmark plan and credit calculation
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