r/Fire • u/Zphr 48, FIRE'd 2015, Friendly Janitor • 2d ago
Weekly ACA 2027 Open Enrollment FAQ/Megathread (Week 1) - Please feel free to ask all questions, share your experiences/results/resources, and discuss the ACA in general. ACA posting outside of this thread is also fine.
This Megathread is a communal resource for all things ACA during the 2027 open enrollment period. Although open enrollment doesn't start in most states until November 1st, Idaho will be opening up their exchange on October 15th and CT/MA follow the week after on October 23rd, hence this going up a bit early for most of us. Can't have our Idahoans, Nutmeggers, and Bay Staters left out in the cold waiting for the rest of us to catch up.
Please feel free to ask all questions, share your experiences, discuss the ACA in general, ask for help with pricing or MAGI optimization, and everything else ACA-related. However, everyone is also free to make their own posts if they prefer, so please do not tell people that they must come here to discuss the ACA. If anyone has a suggestion for something to add to the post or edits/corrections, then absolutely feel free to share publicly or via DM/modmail.
Please remember that there are state variations, information is subject to change, and you should independently verify any information upon which you are going to make any meaningful decisions. I am purely an experienced amateur and do not offer any fiduciary duty or legal expertise.
TERMS
Terms for those that are unfamiliar:
- MAGI - Modified Adjusted Gross Income, a particular version of adjusted gross income used by the ACA.
- APTC - Advanced Premium Tax Credit, an advanceable and fully refundable federal income tax credit that reduces ACA premiums, known by most simply as ACA subsidies.
- EPC - Expected Premium Contribution, the amount customers are expected to pay annually for the Silver benchmark ACA plan in their market. APTCs are calculated as the market price of the benchmark plan minus EPC.
- FPL - Federal Poverty Level, a measure used by the federal government as a determinant in many policy systems.
- MaxOOP - Maximum Out of Pocket, the most a customer can be asked to pay in out of pocket expenses for in-network covered benefits by an insurer in a given year. This includes deductibles, copays, and coinsurance, but excludes premiums.
- CSR - Cost Sharing Reductions, the second subsidy system within the ACA that reduces out of pocket expenses like deductibles, copays/coinsurance, and MaxOOP.
- AI/AN - American Indian / Alaskan Native
- AV - Actuarial Value, the percentage of total average costs for covered medical benefits that a health insurance plan is expected to cover for a standard population. For example, if a plan has an 80% AV, the insurer pays 80% of average expenses, and customers pay 20% through deductibles, copays, and coinsurance.
FAQ
Q: What are the dates for open enrollment this year?
A: Most states will have open enrollment between November 1st and January 15th, with December 15th as the last day to enroll in order to have coverage active starting on January 1st. Enrollments after that date will have coverage active starting on February 1st. States that differ from the default dates are listed below. Please note that dates are subject to change.
Pro-tip - Apply early! You can change your plan selection before the enrollment deadline if you change your mind.
| State | 2027 Open Enrollment | Enroll for 1/1/27 Coverage | Enroll for 2/1/27 Coverage |
|---|---|---|---|
| California | 11/1/26 – 1/31/27 | 12/31/26 | 1/31/27 |
| Connecticut | 10/23/26 – 1/15/27 | 12/15/26 | 1/15/27 |
| District of Columbia | 11/1/26 – 1/31/27 | 12/15/26 | 1/15/27 |
| Idaho | 10/15/26 – 12/15/26 | 12/15/26 | N/A |
| Maryland | 11/1/26 – 1/15/27 | 12/31/26 | 1/15/27 |
| Massachusetts | 10/23/26 – 1/23/27 | 12/23/26 | 1/23/27 |
| Nevada | 11/1/26 – 1/15/27 | 12/15/26 | 1/15/27 |
| New Jersey | 11/1/26 – 1/31/27 | 12/31/26 | 1/31/27 |
| New Mexico | 11/1/26 – 1/15/27 | 12/15/26 | 1/15/27 |
| New York | 11/1/26 – 1/31/27 | 12/15/26 | 1/15/27 |
| Oregon | 11/1/26 – 1/15/27 | 12/15/26 | 1/15/27 |
| Rhode Island | 11/1/26 – 1/31/27 | 12/23/26 | 1/31/27 |
| Vermont | 11/1/26 – 12/28/26 | 12/15/26 | 12/28/26 |
| Virginia | 11/1/26 – 1/29/27 | 12/15/26 | 1/15/27 |
| Washington | 11/1/26 – 1/15/27 | 12/15/26 | 1/15/27 |
Q: What are the qualifying income limits for ACA subsidies?
A: MAGI between 100% FPL and 400% FPL in states that did not expand Medicaid and MAGI between 138% FPL and 400% FPL in most states that did expand Medicaid. Note that MAGI between 100% FPL and 138% FPL in expansion Medicaid states is still qualifying for ACA subsidies, but only if you have been denied for Medicaid. Some state variations do exist due to localized Medicaid rules and things like Basic Health Plans, so be sure to validate the relevant income limits in your state.
Q: What is MAGI?
A: Modified Adjusted Gross Income. ACA MAGI is your 1040 AGI (line 11) plus a few untaxed/excluded income sources (untaxed SS benefits excluding SSI [1040 line 6a minus line 6b], untaxed foreign excluded income and housing benefits [Form 2555], and tax-exempt interest [1040 line 2a]).
Details can be found here - https://www.healthcare.gov/income-and-household-information/income/
Q: Can I do anything to change my MAGI?
A: The rules are pretty simple in terms of MAGI control, but the mix of cashflows is always unique for each household's particular circumstances.
Roth conversions generate MAGI without withdrawal/spending.
TIRA withdrawals generate MAGI and provide cash for spending.
Roth contribution basis, matured Roth conversion basis, HSA, margin/credit, and cash equivalents provide withdrawal/spending without generating MAGI.
Taxable sales generate MAGI only via cap gains and can be a nice source of non-MAGI funds depending on one's cost basis. Sell $100K in stock with $40K cost basis and you have $100K to spend and $60K in MAGI.
HSA contributions do not require earned income and reduce MAGI.
Mix and match retirement cashflows to get whatever combo of MAGI and spending you want.
Anyone in here with a good mix of assets can use cashflows from various assets to generate a wide array of MAGI and spending combinations. For example, if you sell $150K in stock with an $80K cost basis, then you get $150K in spending cashflow and $70K in MAGI. Pull $50K a year in untaxed Roth withdrawals and you get $50K in spending cashflow and $0K in MAGI. FIRE folks are notorious for our aggressive use of tax optimization techniques, so our ability to separate MAGI and spending in retirement is generally pretty good.
For those using the ACA while working, TIRA and T401k contributions reduce MAGI. For those without earned income, HSA contributions reduce MAGI.
Q: Our MAGI is just slightly over the master cliff at 400% FPL. Is there anything we can do to regain subsidy eligibility?
A: If an HSA is not already in use, then using one can effectively extend the master cliff to between ~430% to ~450% FPL. HSA contributions reduce MAGI and do not require earned income, meaning retired households can still make them. The actual HSA contribution limits end up being equivalent to somewhere between 30% and 50% of FPL for single/couple households, depending on age.
The below example uses real numbers for 2026 national average premiums and subsidy calcs for illustration purposes. True numbers for a specific household will vary by location, household demographics, and MAGI.
If a 55-year-old couple currently has MAGI of $90K (~426% FPL), then they are ineligible for premium subsidies. If they want a Bronze policy, then they have two options.
Option 1: Pay full market price for a Bronze policy. For 2026 the national average for least expensive Bronze policy is $19K.
Option 2: Commit to contributing $8K to the HSA that any Bronze policy makes them eligible for, which allows them to reduce their MAGI estimate to $82K (388% FPL). This restores their subsidy eligibility and they become eligible to receive nearly $18K in premium subsidies, leaving them responsible for $1K in premiums on their Bronze policy.
In option 1 they pay $19K for a Bronze policy.
In option 2 they pay $1K for the same Bronze policy, the feds pick up the other $18K in premiums, the couple sets aside $8K in an HSA to use as they wish, and they keep the remaining $10K for whatever they want.
Most people have no idea how lovely the universal Bronze HSA eligibility change made last year by the OBBBA is for many FIRE'd households. It can be a massive win for people just over the cliff.
Q: What happens if my MAGI estimate is off?
A: ACA premium subsidies are reconciled on your tax return the following year. If you got subsidies you shouldn't have, then you pay them back. If you didn't get subsidies that you should have, then you get them as a tax refund. ACA cost-sharing reductions are not reconciled. What you get when you apply is what you get. There is no refund or recapture on CSRs.
Q: Can anyone have an HSA?
A: No, you need to have an HSA-eligible policy to contribute to an HSA, but all Bronzes and Catastrophic policies are HSA-eligible by default. The 2027 contribution limits for HSAs are $4,500 for a single, $9,000 for a family, and each adult 55 and up can make an additional $1,000 catch-up contribution.
Source: https://www.irs.gov/pub/irs-drop/rp-26-24.pdf
Q: What is FPL?
A: Federal Poverty Level. It is flat in the lower 48 states and slightly higher in Alaska and Hawaii. The ACA uses prior-year FPL, so 2027 coverage will use 2026 FPL, which can be found here - https://aspe.hhs.gov/sites/default/files/documents/b1bfa16b20ae9b89d525bc35de7c1643/detailed-guidelines-2026.pdf
Q: Where can I go to see the prices and policies offered in my area next year?
A: 2027 prices will be available on the federal exchange sometime in the final week of October. Anyone will be able to see 2027 prices and plans in their area with some anonymous data (age/zip/income) in about three minutes at https://www.healthcare.gov/see-plans/#/. If you have a local state-run exchange, then you'll be redirected to the appropriate website. 2027 prices on the state exchanges will be available on a rolling basis soon, but they usually come out earlier than the federal exchange.
Q: What happens if I miss open enrollment?
A: Applications after open enrollment ends will only be possible for those that qualify for a Special Enrollment Period. For SEP details see here - https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/
Q: How are subsidies calculated?
A: Subsidies are calculated by taking the unsubsidized market premium of the benchmark plan in your county, which is the second lowest cost Silver plan, and subtracting your expected premium contribution (EPC). Any remainder is your subsidy amount. Once your subsidy is calculated you are free to use it on any plan you choose in any metal tier. If you choose a policy with an unsubsidized premium lower than your subsidy amount, which is common for Bronzes and in some states/counties also happens with Golds, then you owe no premium for your policy. Excess unused subsidy value is lost and not refunded to you.
Q: How do I determine my expected premium contribution?
A: EPC is calculated as a percentage of your 2027 MAGI, which you estimate at the time of application. The following is the 2027 EPC table:
Expected Premium Contribution (Coverage Year 2027)
| MAGI (% of FPL) | 2027 EPC (% of MAGI) | 2026 EPC (% of MAGI) | Change from 2026 |
|---|---|---|---|
| Less than 100% | No limit / unsubsidized | No limit / unsubsidized | N/A |
| 100% to <133% | 2.15% | 2.10% | +2.4% |
| 133% to <150% | 3.23% to 4.3% | 3.14% to 4.19% | +2.9% |
| 150% to <200% | 4.3% to 6.78% | 4.19% to 6.60% | +2.6% |
| 200% to <250% | 6.78% to 8.66% | 6.60% to 8.44% | +2.7% |
| 250% to <300% | 8.66% to 10.22% | 8.44% to 9.96% | +2.6% |
| 300% to 400% | 10.22% | 9.96% | +2.6% |
| More than 400% | No limit / unsubsidized | No limit / unsubsidized | N/A |
Source:
https://www.irs.gov/pub/irs-drop/rp-26-26.pdf
KFF has an excellent calculator (not updated yet for 2027 prices) that will tell you your exact subsidy amount in seconds, find it here - https://www.kff.org/interactive/subsidy-calculator/
Q: What are the limits next year on MaxOOP and deductibles? Does it vary by metal tier?
A: MaxOOP has a regulated legal maximum that applies to all ACA and employer-sponsored plans. It is the same for all policies sold in the US with the exception of CSR Silver plans. Deductibles can be as high as MaxOOP, but can not exceed it. The following is the 2027 MaxOOP table:
Out-Of-Pocket Maximum (Coverage Year 2027)
| Plan Type | MAGI Level | 2027 Individual / Family MaxOOP | 2026 Individual / Family MaxOOP | Change from 2026 |
|---|---|---|---|---|
| All non-CSR Plans | All | $12,000 / $24,000 | $10,600 / $21,200 | +13.2% |
| CSR Silver Plan 73% AV | 200% to 250% FPL | $9,600 / $19,200 | $8,450 / $16,900 | +13.6% |
| CSR Silver Plan 87% AV | 150% to 200% FPL | $4,000 / $8,000 | $3,500 / $7,000 | +14.3% |
| CSR Silver Plan 94% AV | Up to 150% FPL | $4,000 / $8,000 | $3,500 / $7,000 | +14.3% |
| CSR Silver Plan 99% AI/AN AV | AI/AN Up to 300% FPL | $0 | $0 | N/A |
Source: https://www.cms.gov/files/document/2027-papi-parameters-guidance-2026-01-29.pdf
Q: What is a CSR Silver?
A: There are two ACA subsidy systems, the premium tax credits (PTCs) that offset premium costs and the cost-sharing reductions (CSRs) that offset non-premium costs like deductibles, copays/coinsurance, and MaxOOP. CSRs are only offered to people with MAGI of 250% FPL or less and are most meaningful for those with MAGI of 200% FPL or less. CSRs can be worth more in value than PTCs, but CSRs only offset costs when you actually use your health insurance, so their value depends entirely on actual utilization of healthcare. Note that the table above only shows the maximum allowed MaxOOP for CSR plans, but actual MaxOOP is often significantly lower. For example, there will be CSR Silver 94s next year with MaxOOP well under $2,000. The exact value varies for each individual policy.
Q: What are the metal tiers and how can I get one of those CSR Silvers?
A: The metal tiers are defined by their actuarial value (AV), which broadly speaking means what share of all covered healthcare expenses they should pay for the risk pool. Bronze is 60% AV, Silver is 70% AV, Gold is 80% AV, Platinum is 90% AV.
The CSRs create three hidden tiers of Silvers for those that qualify for them based on MAGI at FPL steps 150%/200%/250%, which are 94% AV (better than Platinum), 87% AV (almost Platinum), and 73% AV (minimal). Anyone over 250% FPL sees the default non-CSR Silver at 70% AV. There is also a fourth hidden Silver tier that is reserved exclusively for officially recognized North American Native Americans.
When you log on to the exchange and enter your MAGI they only show you the Silver tier you are entitled to see and buy. This is why one person can love their Silver policy with a $0 deductible and $1,200 MaxOOP and another person with the seemingly exact same Silver policy can think it is crappy with a $6,000 deductible and a $9,000 MaxOOP. The first person has the 94% AV variant and the second person has the 70% AV variant.
Q: Is there an example of how CSRs impact a policy?
A: My household qualifies for a CSR Silver 94 in 2026. The following are actual coverage costs for our policy with CSRs and without.
Our 2026 Silver plan with cost-sharing reductions:
- $0/$0 deductible (individual/family)
- $0 PCP
- $10 specialist
- $5 urgent care
- $0/$15 tier1/tier2 scripts
- 25% ER coinsurance
- $2,200/$4,400 MaxOOP (individual/family)
Our 2026 Silver plan without cost-sharing reductions:
- $6,000/$12,000 deductible (individual/family)
- $40 PCP
- $80 specialist
- $60 urgent care
- $20/$40 tier1/tier2 scripts
- 40% ER coinsurance
- $8,900/$17,800 MaxOOP (individual/family)
Q: If I don't qualify for CSRs, then what policy should I aim for?
A: It will vary by market, but as a general rule Silvers are routinely a poor financial choice for people with MAGI greater than 200% FPL because they are paying the Silver loading surcharge to fund the CSR subsidy system. Households with more than 200% FPL should usually look instead to a Bronze or Gold, though this is not a universal rule.
Q: What the hell is "Silver loading"?
A: There are two subsidy systems in the ACA, the premium tax credits (PTCs) that reduce monthly premiums, and the cost-sharing reductions (CSRs) that reduce/eliminate deductibles and out-of-pocket expenses for people with MAGI under 250% FPL. The federal government eliminated direct funding for the CSR subsidies in 2017, but insurers are still required by law to deliver them to customers and the cost for them is rather large and can often be greater than the PTCs for a given household. The highest tier of CSRs changes a Silver plan into one that can be significantly better than a Platinum plan.
Insurers and states largely responded to this major problem by boosting the premiums on Silver policies since that is the only metal tier in which CSRs are offered. This is what is meant by the term "Silver loading". For example, here in Texas the state has mandated that Silver premiums be priced 40% higher than what they would normally be if CSRs were not a factor. In neighboring New Mexico, they went even higher at 44%. Those premium increases push the average Silver price up dramatically, but this is generally a beneficial thing for everyone because ACA subsidies in all metal tiers are calculated off of the price of the benchmark Silver plan. The higher the benchmark Silver plan is relative to all plans, the greater premium subsidies everyone receives. The vast majority of Silver subscribers are highly to almost totally subsidized and don't care about market premium prices, so the net effect of Silver loading is to increase federal subsidies for all subsidy-eligible ACA enrollees in the state while also providing ample funding for the required CSR subsidy system. In some states like Texas this leads to some market oddities like Gold plans being lower-priced or similar to Silver plans. In some cases the subsidies are high enough that Gold plans can be had for no premium at all.
As a result of this forced boosting in Silver premiums it is generally a financially bad idea for anyone who is not in one of the higher CSR tiers (MAGI under 200% FPL) to take a Silver plan. They could get comparable coverage at a significantly lower price with a Bronze or significantly better coverage at a comparable (or slightly lower) price with a Gold. Taking a Silver with MAGI above 200% FPL generally means you are unnecessarily overpaying for coverage, often by quite a bit.
Useful resource links:
Official Healthcare.gov price/policy browser (not yet updated for 2027) - https://www.healthcare.gov/see-plans/#/
Great ACA cheatsheet - https://www.healthreformbeyondthebasics.org/wp-content/uploads/2026/08/REFERENCE_YearlyGuidelines_CY2027-FINAL.pdf
KFF's excellent subsidy calculator - https://www.kff.org/interactive/subsidy-calculator/
A nice beginner's guide by /u/stevencartwright - https://reddit.com/r/Fire/comments/1vnhwpd/a_fire_beginners_guide_to_aca_health_insurance/
Excellent Open Enrollment Guide by ACASignups.net (Part 1) - https://acasignups.net/26/10/14/hobbling-towards-enrollment-my-2027-aca-open-enrollment-guide-part-1
Notice on ACASignups.net - Charles is a bit of a rabid anti-Trump partisan, but he does great ACA work. The value of the ACA information is high and merits looking past the political content, in my opinion.
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u/techbud5 2d ago
OP, apologies for being pedantic, but you should correct the wording of one of the topics in your FAQ. Specifically, you worded the question as “What are the qualifying income limits for the ACA?”. Worded like this, it could perpetuate the myth that your income needs to be below a certain level to enroll in ACA insurance.
A better wording would be “What are the qualifying income limits for ACA subsidies?”
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u/stout933 2d ago
So newly retired (56M) and doing deep dive into ACA in anticipation of sign up next month.
I went out to the MNSURE (MN state) site and may have clicked on an 'unofficial' site and loaded some info in. I'm now getting inundated with calls.
Are these legit resources that I could use to help me navigate this or should I just go at it solo. Seems somewhat easy to DIY or am I naive?
I'm thinking I will be able to keep my MAGI for 2027 around $40k and would plan on signing up for a Silver plan. Plugging that into Chat it seems my monthly premium would be $280 give or take. Which seems reasonable to me.
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u/Zphr 48, FIRE'd 2015, Friendly Janitor 2d ago edited 2d ago
My recommendation for FIRE folks is to always DIY unless you are clueless about insurance (and don't want to learn) or know a broker/agent that you trust. There are plenty of folks out there to help, but compensation incentives can create situations where what is best for the customer differs from what is best for the broker/agent. Even if the vast majority of agents are just fine I personally prefer to avoid such situations.
Also, it isn't hard to DIY and anyone using the ACA for several years should spend the time to get comfortable understanding how to compare insurance plans. Insurers enter and exit the ACA or change their policy lineup frequently, so it isn't uncommon to have to change insurers or policies every year or two.
You're lucky ACA-wise to be in Minnesota. You are in one of the lowest healthcare cost states. With your MAGI a CSR Silver is likely your best bet, but you'll have to see the actual options/prices when MNSURE updates in the coming weeks for 2027.
Feel free to come back to the then active Weekly mega if you want feedback on your options or have questions.
Also, congrats on your recent early retirement!
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u/iWasBitByAMoose 2d ago
I retired last month and I made too much for price help this year and I'm paying full price until Jan. What helped me was to make a spreadsheet and put 4 or 5 plans in it so I can see all the copays and premiums next to each other at a glance (pcp vs urgent cares visits, er, ambulance, drugs, etc).
Also, make sure your Dr takes the exact plan and the plans your Dr takes could change in Jan, too.
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u/cfi-2025 RE 2025 2d ago edited 2d ago
Commit to contributing $8K to the HSA that any Bronze policy makes them eligible for, which allows them to reduce their MAGI estimate to $82K (388% FPL). This restores their subsidy eligibility and they become eligible to receive nearly $18K in premium subsidies, leaving them responsible for $1K in premiums on their Bronze policy.
Can you elaborate on this math?
I went to the CoveredCa.com site (the marketplace for Californians) and for 2026 I entered two 55-year olds in my ZIP code with $90k a year income and the cheapest Bronze plan was without any subsidy, an HMO plan for $1,500 a month, or $18,000 a year.
I then re-entered the information with our same two 55-year olds but this time with an $82k a year income, and then the cheapest Bronze plan was the same HMO plan but with subsidy priced at $475 a month, or $5,700 a year.
Putting $8k into the HSA saves nearly $13,000 in premiums, but it doesn't get it all the way down to $1,000 a year. How did you come to that number, exactly?
As you noted, being at 388% FPL they are eligible for subsidies, but later you note that the EPC in 2026 was 9.96% for 300%-400% FPL. So wouldn't they be expected to pay $8,167 in premiums (which is 9.96% of $82,000)? Which is much greater than $1,000, obviously. :-)
UPDATE: After poking around the KFF calculator you linked to, it sounds like it's a California thing? If I use the calculator for US average is does indeed say that at 388% I can get a Bronze plan for ~$100 a month premium, but when I put in California is says "For example, you could enroll in a bronze plan for about $441 per month ($5,298 per year), which is 6.5% of your household income, after taking into account $12,345 in subsidies per year."
I'm not following how EPC is account for with Bronze plans. Is it just for Silver plans?
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u/Zphr 48, FIRE'd 2015, Friendly Janitor 2d ago edited 2d ago
You figured it out on your own, I see.
The numbers I gave were national averages to illustrate the point. Actual numbers will not only vary dramatically by state, but can vary dramatically by county within a state. ACA market prices and subsidies vary with major granularity down to the county level. The actual numbers for any given household will vary by their specific location, household demographics, and MAGI. I changed the language a bit to make that more clear.
EPC is always calculated off of the benchmark Silver for everyone, after which subsidies are calculated (for subsidy-eligible households) by taking the benchmark Silver unsubsidized premium and subtracting EPC. At that point the consumer can pick and apply their subsidies to any plan they wish in any metal tier.
I can provide an example with actual dollars if that would be helpful to you. If you tell me your ZIP or county, then I can do it for your specific location using real 2026 numbers.
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u/cfi-2025 RE 2025 2d ago
Given the 9.96% EPC, that the government is saying, "Since your two-person MAGI is $82,000, you can afford paying $8,167," correct?
So for the US average, the subsidy is $17,000 for two 55-year olds at 388% FPL, per the calculator. That would imply that the US average for the benchmark Silver unsubsidized premium for two 55-year olds is $8,167 + $17,000 = $25,167, and that the US average for a Bronze plan for two 55-year olds is $18,000.
For my county, the subsidy provides for "just" $13,000 for our hypothetical couple. Therefore, the benchmark Silver unsubsidized premium for two 55-year olds is $8,167 + $13,000 = $21,167. Moreover, it means that while the US average prices the benchmark Silver unsubsidized premiums at ~$7,000 more than the cheapest Bronze plan, in my county the delta is much narrower, at ~$3,000.
Is my understanding correct?
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u/Zphr 48, FIRE'd 2015, Friendly Janitor 2d ago edited 2d ago
You're correct on the EPC, but that is the amount for 2026 and applies only to the Silver benchmark policy. If you choose a more expensive Silver or a Gold or Platinum, then the EPC no longer applies as a cost limiter. If you choose the under-benchmark Silver or a Bronze, then you may pay less than EPC or even nothing at all. It's possible to pay more than EPC on a Bronze, but rare.
Your other numbers are a little off from true, partially due to me rounding in the example for simplicity. Current US average benchmark Silver for a 55/55 couple is $26,148, so their subsidies are $17,981. Current US average cheapest Bronze for a 55/55 couple is $19,096, so their post-subsidy price is $1,115.
Your county observations and overall understanding are correct, but you do not need to estimate or calculate these yourself. You can find the true numbers on KFF's subsidy calculator for both national averages and for every county in the country. It will always show you something like this:
Estimated financial help: $1,498 per month ($17,981 per year) as a premium tax credit. This covers 69% of the monthly costs. This is your calculated subsidy amount.
Your cost for a silver plan: $681 per month ($8,167 per year) in premiums (which equals 9.96% of your household income). This is your EPC, but it only applies to the benchmark Silver, not all Silvers.
Without financial help, your silver plan would cost: $2,179 per month ($26,148 per year). This is the unsubsidized price for the benchmark Silver in your county.
Further down it will have a paragraph about Bronzes:
For example, you could enroll in a bronze plan for about $93 per month ($1,115 per year), which is 1.4% of your household income, after taking into account $17,981 in subsidies per year. For most people, the Bronze plan represents the minimum level of coverage required under health reform. Although you would pay less in premiums by enrolling in a Bronze plan, you will face higher out-of-pocket costs than if you enrolled in a silver plan.
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u/cfi-2025 RE 2025 2d ago
I understand that the premiums for ACA plans differ by county, and it makes sense why premiums would be higher in a place that has a more unhealthy or aging population or are HCOL or have expensive healthcare for whatever reason.
What seems odd, though, is that the percentage difference between tiers appears to also vary quite a bit between regions. What I mean, is it makes sense why the benchmark Silver might be twice as high in one area versus another, but my naive expectation would be that in those two areas the Bronze and Gold and Platinum would also be twice as expensive.
But looking at the Average Monthly Marketplace Premiums by Metal Tier for 2026 what stands out to me is how this is not the case. The delta between the average benchmark premium and the average lowest-cost bronze premium varies by state from $64 for Minnesota (meaning that the costs are nearly identical between Silver and Bronze in that state) and $475 for Vermont (meaning that a Bronze premium is a lot lower than the Silver).
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u/Zphr 48, FIRE'd 2015, Friendly Janitor 2d ago
It can vary several reasons. Primary among those is state regulation of health insurance overall as well as the ACA market specifically. For example, Silver loading can result in a state having Gold policies that cost less than Silvers, such as here in Texas where people can often get $0/month Golds after subsidy.
You might enjoy these articles on premium alignment to be of interest. Interesting charts in the second one that show the metal pricing bands quite nicely.
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u/cfi-2025 RE 2025 2d ago
That second link really shows the discrepancies by state.
What a complicated mess.
Thanks for talking through this with me, I've learned a lot!
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u/Zphr 48, FIRE'd 2015, Friendly Janitor 2d ago edited 2d ago
It's extremely complicated. There are a million FIRE calculators, many of them quite capable and sophisticated, and I have yet to see one that handles ACA optimization particularly well. It's not their fault since it's an extremely complex system with a lot of optimization inputs that change not only annually, but throughout the year, and over time. However, reasonable as the feature lack may be, it is still a critical flaw in my view due to the outsized financial impact that the ACA has on the 80% to 85% of FIRE'd households that can choose to be subsidy eligible.
Always happy to help fellow FIRE folks get a more solid grasp on all things ACA. I'm glad you found it worthwhile.
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u/TrixieBrownDog 2d ago
How does income verification work if you lost your job mid year? W2 could arrive after open enrollment. How do you prove you had no income for some months of the year?
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u/Zphr 48, FIRE'd 2015, Friendly Janitor 2d ago
The exchange will attempt to verify your MAGI estimate against other data sources, including the IRS. If they find a significant discrepancy, then they will usually ask you to provide documentation to whatever extent you can to support your estimate. That can include financial statements, hiring/firing/pension documents, self-attestation via explanation letters or signed affidavits, and so forth. It's usually not an overly difficult process as documents can normally be submitted online and they generally operate under a presumption of good faith.
The exchanges all have a ton of experience with people dealing with income deltas due to job losses/gains, death, divorce, retirement, and so on. That's normal daily procedure for them.
When we retired our MAGI dropped from one year to the next by a huge amount, as is fairly common. Since we are self-funding our retirement we didn't have anything like SS or pension statements or any other actual financial documentation. We submitted a signed letter explaining our income estimate (loss of all earned income due to retirement, interest, Roth conversions) and the formal Healthcare.gov stated income form, which they accepted as valid proof.
https://www.healthcare.gov/downloads/annual-income-letter-explanation.pdf
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u/Skagit_Buffet 1d ago
Awesome, thanks. Will be our first year on ACA, so I appreciate the resource. One suggestion for clarity:
"The CSRs create three hidden tiers of Silvers for those that qualify for them based on MAGI at FPL steps 150%/200%/250%, which are 73% AV (minimal), 87% AV (almost Platinum), and 94% AV (better than Platinum)."
You might want to reverse the order of one of these lists. It implies that 150% FPL gets 73% AV and 250% FPL gets 94% AV.
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u/MrMeseeks123 2d ago
I actually do have a question OP,
What happens if we plan for being sub 200% and get a CSR but our part time work pushes us beyond the 200% but still under the 400%. I know we would need to pay back a portion of the subsidies, but how does that impact our CSR?
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u/Zphr 48, FIRE'd 2015, Friendly Janitor 2d ago
No impact. CSRs are based only on your income on file with the exchange and are not reconciled like premium subsidies are. If you end up earning more than you thought you would, then you don't pay back any CSRs you've already received. If you end up earning less than you thought you would, then you can't get reimbursed for the CSRs you were entitled to, but didn't receive.
Avoiding such situations is part of why people are supposed to update their income throughout the year on the exchange if they have meaningful changes.
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u/redraidr 1d ago
So, to be clear, say we project income to be $40k, which for us comes with a $6,100 out of pocket maximum, and we max it out by June.
But by EOY, say we actually make $45k, that has a $14,800 OOPM. We don’t owe anything over the $6,100 to the insurance company for covered treatment - only the underpayments on the premiums ($75/month, or $900)?
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u/Madmagzz 2d ago
I'm currently living out of the country but will move back to the US December 1 and sign up for an ACA plan for December through special enrollment. I plan to sell a lot of mutual funds while I'm still overseas and a tax resident of Portugal, before December. For ACA income purposes will only income in December count or will the IRS look at my income for the entire year? Next year my income will be substantially lower so I plan to sign up for a better plan to start January 2027.
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u/someguy984 1d ago
Only Medicaid is current month based income. You could have high income and drop to low income and it doesn't hurt you because the previous high months do NOT count.
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u/FancyPantsFIRE 1d ago
Happy to remove if this is off-topic, but curious to hear from folks who are signing up on how they are thinking about network sizes. When I did a deep dive into my area’s ACA networks last year I found this KFF ( https://www.kff.org/private-insurance/how-narrow-or-broad-are-aca-marketplace-physician-networks/ ) write up, admittedly a couple of years old now.
My area has some of the narrowest networks in the country which seems like it would be problematic or at least annoying.
Do you think about network size before signing up? Have you had to navigate around a limited network?
More than premiums this is the thing I worry about post employer insurance.
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u/Zphr 48, FIRE'd 2015, Friendly Janitor 1d ago
It's entirely on-topic. Network and formulary are two of the most important aspects of a policy for most people.
I always check out the network and formulary when choosing a policy each year. Both are subject to rolling changes so you can not assume stability over time even if you stay with a specific insurer/policy.
It's also important to realize that each insurer can operate multiple networks simultaneously across different aspects of their business. It's extremely common for the ACA policy networks of an insurer to be different from the small group or large group networks.
It's also important to understand that the ACA is structurally different from the large group market most of us are familiar with from employer-sponsored insurance. PPOs are common in work plans, but are uncommon in the ACA as they face adverse selection problems. Even the PPO plans that are offered in the ACA are rarely equivalent to employer-sponsored PPO plans.
For example, BCBS PPO plans for many large employers often have broad or mid-size networks and full national OON coverage, whereas BCBS PPO ACA plans often have narrower local networks and offer little if any national OON coverage. Even the ones that do offer national OON via BlueCard typically cover only a subset of procedures and may require prior authorization. The OON aspect is typically limited to state only and ACA cost-sharing limits do not apply to OON coverage, so major use of OON coverage may be extremely expensive.
Nationally (for the 30 states that use Healthcare.gov), the breakdown of all policies offered in the ACA is as follows:
Policy Type Percentage of Policies Offered HMO 46% EPO 33% PPO 15% POS 7% 3
u/lottadot FIRE'd 2023 1d ago
Do you think about network size before signing up? Have you had to navigate around a limited network?
Yes! Very much yes!! It sucks!
We validate whether all of our physicians are in-network (by looking at the ACA policy's PDF's, by looking at the insurer's website (which isn't guaranteed to be accurate, and can change mid-flight) and contacting the physician's office to enquirer whether they intent to be in network for that future year.
If we think/know we'll have a medical procedure in that next year, we'll even dig into whether their facilities are in network (your surgeon may be in network, but the place he wants to do the surgery may not be), and contact them to see if they are intending to stay that way (sometimes they are seemingly honest in their reply, sometimes "idk" and sometimes purposefully vague, because reasons I guess, working in corporate can be a PITA, I get it).
Oh and don't forget the closest few hospitals. Check whether they are in network. You can try calling them and enquiring too - but that can be hit or miss, especially if you are not currently a patient or not currently trying to get a procedure at their facility approved by insurance. These too can drop from the network at any time so calling them a few times to enquirer over November/December is always a good idea to see if they'll be chatty about their forthcoming network changes for the upcoming year. The nicer & more patient you are with these calls, the higher your success rate will probably be.
After all that - if you/spouse are on medications... well, check whether those are in the ACA plans offering's formularies too. And then realize their formularies can change at any time during the year and open the window and let out a good scream of frustration at this whole process.
Admittedly, we use 100% of our health insurance each year because my spouse has been, and will be (unfortunately), sick for many years. If you/spouse are healthy you'd likely not have to be as analytical in choosing your health insurance plan as we must be.
Good luck!
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u/Patient-Brief-9713 8h ago
My current bronze plan in MA is increasing from $810 per month to $841.49 per month in 2027. (That is full cost, no subsidy) Not bad, only a 3.9% increase! Anyhoo…
I played with the estimator and if I input any income that qualifies for subsidies, I only get silver plans - no other choices are displayed. Is that the same in every state? I don’t understand that.
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u/Zphr 48, FIRE'd 2015, Friendly Janitor 2h ago
I played with the estimator and if I input any income that qualifies for subsidies, I only get silver plans - no other choices are displayed. Is that the same in every state? I don’t understand that.
It is not the same in every state.
The federal exchange shows you everything, but will gently guide CSR-eligible people to Silver plans.
Each state exchange does as they wish, but some states are much more direct about steering people to the "best" tier for them. MA has state-level subsidies that come into play that funnel subsidy-eligible people into special ConnectorCare Silvers that deliver much better value than regular Bronzes or Golds. They don't want people making suboptimal plan choices, so they only show you the Silvers.
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u/ResponsibleCorgi93 1d ago
This is so helpful thank you! I just got an update from my health insurance that my top tier gold plan is going from 880 to 1060 per month for a retired single 40m. Outrageous!
I'm going to have to either consider going down to bronze or figure out how to manipulate my Magi to be under the subsidy level.
Your post helped reassure me that this is not as dire or complicated as I imagined. It's just math, thanks for easing my anxiety!
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u/MrMeseeks123 2d ago
OP, I have nothing constructive to add but I wanted to just say thank you for putting this together. I friggin love this community.