Summary Cost Data for Health Plans
Available in Delaware’s Exchange, 2014:
Fact Sheet
Nicholas Elan
Research Associate
Bernadette Fernandez
Specialist in Health Care Financing
Annie L. Mach
Analyst in Health Care Financing
April 24, 2014
Congressional Research Service
7-5700
www.crs.gov
R43499
Summary Cost Data for Health Plans Available in Delaware’s Exchange, 2014
he Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) contains a
number of provisions that may affect the individual health insurance market. These
Tprovisions may alter the amounts that individuals and families can expect to pay for
insurance plans sold on Delaware’s exchange. This fact sheet provides a look at selected costs and
options for individual and family plans in Delaware’s exchange.1 (For background information,
see the related overview report, CRS Report R43484, Summary Cost Data for Federally-
Facilitated Exchanges, 2014).
A state resident interested in purchasing an individual plan in his or her exchange may have a
choice of plans that vary in characteristics, such as the share of medical spending the plan will
cover (“actuarial value,” or AV2), the scope of the benefits package (e.g., types of services and
providers covered), and other plan features.3 Under ACA, each plan that meets a specific AV is
designated by a precious metal: platinum, gold, silver, or bronze.4 Exchanges are also allowed to
offer catastrophic plans, with AVs below 60%; such plans are available only to individuals under
the age of 30 and certain others who are exempt from ACA’s individual mandate.5 Given this
potential range in plans, this fact sheet displays premium and cost-sharing data tables for five
categories of health plans, in order of decreasing actuarial value: platinum to catastrophic.
A person or family seeking health insurance faces a tradeoff between the expense of premiums
and cost-sharing requirements. For example, a younger resident expecting to use relatively few
medical services may prefer a lower-tier plan. Although lower-tier plans in general have smaller
premiums, they also have greater cost-sharing requirements, overall. Table 1 summarizes selected
premiums for individual insurance plans available in this state for adults at different ages, and
Table 2 shows selected cost-sharing requirements of the same plans.
Table 1. Monthly Exchange Premiums for Individuals, for Selected Ages
(premium amounts are rounded to the nearest dol ar)
Single Adults, Age 21
Single Adults, Age 40
Single Adults, Age 60
Metal Level
Min. Mediana Max Min. Median Max Min. Median Max
Platinum
$330 $330 $330
$422 $422 $422
$896 $896 $896
Gold
$269 $280 $324
$344 $358 $414
$731 $761 $878
Silver
$224 $226 $269
$286 $289 $343
$607 $614 $729
Bronze
$194 $201 $209
$247 $257 $267
$525 $546 $567
Catastrophicb
$131 $148 $165
$167 $189 $210
$355 $401 $447
1 The data analysis for this report was conducted by CRS using a publicly available data set from Data.Healthcare.gov.
2 Actuarial value (AV) is a measure of a plan’s generosity, expressed as the percentage of medical expenses estimated
to be paid by the insurer for a standard population and set of allowed charges. In other words, the higher the percentage,
the lower the cost-sharing, on average.
3 For descriptions of the variety of health plans that may be offered inside (and outside of) exchanges, see CRS Report
R43233, Private Health Plans Under the ACA: In Brief.
4 Platinum plans have an actuarial value of 90%; gold plans, 80%; silver, 70%; and bronze, 60%.
5 ACA authorizes the Secretary of Health and Human Services to provide exemptions from ACA’s individual mandate
to individuals who have suffered hardship with respect to the ability to obtain coverage under a qualified health plan.
This authority gives the Secretary wide discretion as to what constitutes a hardship, and the individuals and families
who qualify for such exemptions. The ability for exempted individuals and families to enroll in a catastrophic plan
offered through an exchange does not depend on their age.
Congressional Research Service
1
Summary Cost Data for Health Plans Available in Delaware’s Exchange, 2014
Source: CRS analysis of data from Data.HealthCare.gov.
Notes: The listed premiums are pre-subsidy figures; they do not reflect the premium tax credits that will in
effect reduce these prices for many individuals with incomes that fal below 400% of the federal poverty level.
Differences between listed premiums may also be attributed to variables not considered in the table, such as
geographic rating areas within a state. Child-only plans are excluded.
a. A median is the middle value of an ordered sequence. For each median premium, half of the set of
premiums are above its value and half below it. This is in contrast to the arithmetic mean, an alternative
measure of central tendency, which is the sum of a set of values divided by the number of values. Median
premiums were drawn from an ordered list of premiums for all plans offered in all rating areas in the state.
b. Catastrophic plans are available only to individuals under the age of 30 and certain others who are exempt
from the ACA’s individual mandate (regardless of age).
The premiums and cost-sharing amounts listed in these tables are based on all plans offered in the
state at the appropriate metal level (AV). Individuals may choose from plans within insurance
rating areas. Individuals in a specific rating area may have a more limited range of plans,
premiums, and cost-sharing options than those shown in these state-level tables.
Table 2. Annual Exchange Cost-Sharing Requirements for Individuals
Maximum Out-of-Pocket
Medical Deductible
Expenses
Metal Level
Min. Median Max Min. Median Max
Platinum
$300 $300 $300
$1,300
$1,300
$1,300
Gold
$0 $1,500 $1,800 $1,800 $3,000 $5,000
Silver
$3,000 $3,000 $3,750 $3,000 $5,000 $6,350
Bronze
$5,250 $5,950 $6,300 $6,250 $6,300 $6,350
Catastrophic $6,350 $6,350 $6,350 $6,350 $6,350 $6,350
Source: CRS analysis of data from Data.HealthCare.gov.
Notes: Some individuals with incomes below 250% of the federal poverty level may be eligible for cost-sharing
subsidies, which would have the effect of reducing the listed cost-sharing burdens.
ACA generally requires exchange plans to limit annual out-of-pocket (OOP) expenses to specific
levels. For 2014, the annual OOP limits for individual and family plans are $6,350 and $12,700,
respectively. Given these limits, exchange plans with lower actuarial values may use the OOP
limits to also establish deductible levels.
Just as an individual may consider premiums and cost-sharing when seeking insurance, a family
may likewise make such a comparison. For example, a family that either expects to use a high
volume of medical services or wants to assume less financial vulnerability to a large medical bill
may prefer to select a higher-tier plan with larger premiums in order to have less burdensome
cost-sharing requirements, such as a low deductible. Table 3 shows the range of premiums for
family insurance plans in the state for hypothetical families at selected ages, and Table 4 shows
the range of selected cost-sharing requirements for those plans.
Congressional Research Service
2
Summary Cost Data for Health Plans Available in Delaware’s Exchange, 2014
Table 3. Monthly Exchange Premiums for Families, for Selected Ages and Family
Composition
(premium amounts are rounded to the nearest dol ar)
Individual, Age 40, with Two Children
Couple, Age 40, with Two Children
Metal Level
Min. Median Max Min. Median Max
Platinum $841
$841
$841
$1,262
$1,262
$1,262
Gold $686
$714
$824
$1,030
$1,073
$1,238
Silver $570
$577
$684
$856
$866
$1,028
Bronze $493
$513
$532
$741
$770
$799
Catastrophic $334 $376 $419 $501 $565 $630
Source: CRS analysis of data from Data.HealthCare.gov.
Notes: The listed premiums are pre-subsidy figures; they do not reflect the premium tax credits that will in
effect reduce these prices for many families with incomes that fall below 400% of the federal poverty level.
Differences between listed premiums may also be attributed to variables not considered in the table, such as
geographic rating areas within a state. Median premiums were drawn from an ordered sequence of premiums for
all plans offered in all rating areas in the state. Child-only plans were excluded.
Table 4. Annual Exchange Cost-Sharing Requirements for Families
Maximum Out-of-Pocket
Medical Deductible
Expenses
Metal Level
Min. Median Max Min. Median Max
Platinum $600
$600
$600
$2,600
$2,600
$2,600
Gold
$0 $3,000 $3,600 $3,600 $6,000 $10,000
Silver $6,000
$6,000
$7,500
$6,000
$10,000
$12,700
Bronze
$10,500 $11,900 $12,600 $12,500 $12,600 $12,700
Catastrophic $12,700 $12,700 $12,700 $12,700 $12,700 $12,700
Source: CRS analysis of data from Data.HealthCare.gov.
Notes: Some families with incomes below 250% of the federal poverty level may be eligible for cost-sharing
subsidies, which would have the effect of reducing the listed cost-sharing burdens.
Some exchange enrollees may be eligible for federal tax credits to help them pay the insurance
premium. The credits are provided to low- and middle-income individuals and families; in
general, larger credit amounts are provided to those with lower incomes. While some individuals
will receive a credit generous enough to pay for the entire premium, some individuals will still
have to pay some amount toward the monthly premium. Because the credit is based on income,
the remaining amount the individual would pay after receiving the credit generally will be the
same among individuals with the same income, regardless of the state or local area.6
For example, consider the pre-credit premiums for one person age 21 and another person age 60
(see Table 1). For purposes of this example, assume that the median premiums at the silver tier
6 There are exceptions to this general rule. For a comprehensive discussion about premium tax credits, see CRS Report
R41137, Health Insurance Premium Credits in the Patient Protection and Affordable Care Act (ACA).
Congressional Research Service
3
Summary Cost Data for Health Plans Available in Delaware’s Exchange, 2014
represent the standard plan on which the credit formula is based: $226 for the 21-year-old, and
$614 for the 60-year-old. Under this premium credit formula, a person with income that is
equivalent to the federal poverty level (FPL)7 may pay up to $20 a month toward premiums for a
standard plan.8 At this income level, the resulting premium credit amounts would differ by age.
The 21-year-old may pay up to $20 a month, with a credit amount of $206. The 60-year-old may
also pay $20, but with a credit of $594.
Table 5 shows the number of plans available to someone purchasing an exchange plan in
Delaware. Because Delaware only has one geographic rating area, individuals in the state
generally have access to the same plans, regardless of where the individuals reside.
Table 5. Exchange Plan Availability
(Delaware has one geographic rating area)
Number of Health Plans
Available in a Given Rating Number of Rating Areas with
Metal Level
Areaa
More than One Plan Option
Platinum
1
0 out of 1 rating area
Gold
9
1 out of 1 rating area
Silver
5
1 out of 1 rating area
Bronze
4
1 out of 1 rating area
Catastrophic
2
1 out of 1 rating area
Source: CRS analysis of data from Data.HealthCare.gov.
Notes: Under ACA, geographic rating areas may be used as the basis for premium variation within a state.
Rating areas can be based on counties, three-digit zip codes, or metropolitan statistical areas.
a. A single number in this column indicates that all rating areas in the state offer the same number of plans in a
given metal level. A set of numbers indicates that at least some rating areas in the state offer different
numbers of plans in a given metal level. Child-only plans are excluded from this analysis.
7 For 2014 premium credit purposes, the income level equivalent to the federal poverty level is $11,490 for one person
residing in this state.
8 The amount is based on a standard plan (the second-lowest cost silver plan in the person/family’s local area), and the
poverty level applicable to the 48 contiguous states and DC. Different amounts would apply to Alaska and Hawaii, and
for any other metal tier plan.
Congressional Research Service
4
Summary Cost Data for Health Plans Available in Delaware’s Exchange, 2014
Author Contact Information
Nicholas Elan
Annie L. Mach
Research Associate
Analyst in Health Care Financing
nelan@crs.loc.gov, 7-0688
amach@crs.loc.gov, 7-7825
Bernadette Fernandez
Specialist in Health Care Financing
bfernandez@crs.loc.gov, 7-0322
Congressional Research Service
5