The five things that can legally change your price
Age, tobacco, county, household size and plan choice. Everything else — including your medical history — is off the table.
An insurer selling a marketplace plan may set your price on five things. The list is closed — anything not on it may not be used, and that includes most of what insurers used before 2014.
1. Your age
Age is the largest legal factor, and it is capped. A 64-year-old may not be charged more than three times what a 21-year-old pays for the same plan in the same place. Below 21 the rate is flat; above it, it steps up each year to that ceiling. Some states compress the ratio further.
Because the cap is a ratio rather than a fixed amount, its effect is larger in expensive markets than cheap ones.
2. Tobacco use
A surcharge of up to 1.5 times the base premium is permitted. Two things about it are widely misunderstood: the premium tax credit is calculated before the surcharge, so the credit does not help pay it and the full amount falls on you. And several states ban the surcharge outright or cap it below the federal limit.
3. Where you live
Not your state — your rating area, which each state builds from counties. This is why two people in the same state with identical circumstances can be quoted different prices, and it is the factor most consumer writing skips.
The practical difference is competition. Among the counties on this site, Wichita County in Texas has 1 insurer selling 19 plans between them, while Broward County in Florida has 13 insurers selling 197. A benchmark set by 13 competing insurers is a different number from one set by 1.
4. How many people are on the plan
Family premiums are built by adding up individual rates, not by applying a family multiplier. Children under 21 are rated flat, and only the three oldest children under 21 are charged — a fourth and any beyond add nothing to the premium.
5. Which plan you pick
The metal tier, and the individual plan inside it. Within a single tier, plans from different insurers in the same county routinely differ by hundreds of dollars a year, with different networks and drug formularies behind those prices.
What may not be used
This is the part worth reading twice if you last bought insurance before 2014.
- Health status — current or past.
- Pre-existing conditions — they may not raise your price, and they may not be excluded from coverage.
- Sex.
- Claims history.
- Occupation or industry.
- Genetic information.
There is no medical underwriting on a marketplace plan. No questionnaire, no medical exam, and no possibility of being turned down for a plan sold in your county during a period when you are eligible to enroll.
Plans sold outside the marketplace are a different matter. Short-term limited-duration policies and some fixed-indemnity products are not ACA plans, may underwrite on health, and may exclude pre-existing conditions. They are frequently advertised alongside marketplace plans and are not the same product.