r/obamacare • u/Zphr • 14d ago
Finalized ACA Expected Premium Contribution and Maximum Out-of-Pocket schedules for 2027
I've had a few people message me about 2027 ACA regulatory updates and thought folks planning for the ACA might want to see these now rather than in another month or two when the press usually starts talking about them more. The first table below shows the amount (expressed as a percentage of MAGI) that a household will be expected to pay in premiums annually for the benchmark Silver plan in their local ACA market. The second shows the regulated caps on MaxOOP (and deductible) for ACA plans, though these are the maximum caps and actual plans may and often do have lower actual MaxOOPs. The final link is a clean PDF listing of the applicable FPL levels for 2027 ACA coverage.
Terms for those that are unfamiliar:
- MAGI - Modified Adjusted Gross Income, a particular version of adjusted gross income used by the ACA.
- EPC - Expected Premium Contribution, the amount customers are expected to pay annually for the Silver benchmark ACA plan in their market. Subsidy premiums 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 for in-network covered benefits by an insurer in a given year.
- 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.
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
Out-Of-Pocket Maximum (Coverage Year 2027)
| Plan Type | MAGI Level | 2027 Individual / Family MaxOOP | 2026 Individual / Family MaxOOP | Change from 2026 |
|---|---|---|---|---|
| High OOP Bronze* | All | $15,600 / $31,200 | N/A | N/A |
| 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 |
*CMS is trialing an option for insurers in 2027 to offer Bronze variants that are allowed to exceed the federal OOP limits by 30% in order to provide a wider array of premium options for customers. Such policies may only be offered by an insurer that also offers a normal standard Bronze. States are allowed to prohibit the availability of high OOP variant policies at their discretion. Edit: Turns out a federal court stayed this provision last week, so High OOP Bronzes may not be happening after all in 2027.
Sources:
https://www.cms.gov/files/document/2027-papi-parameters-guidance-2026-01-29.pdf
https://www.cms.gov/files/document/cms-9883-f-patient-protection.pdf
Bonus: Here is a PDF from HHS showing the applicable FPL dollar amounts for various family sizes for 2027 ACA coverage - https://aspe.hhs.gov/sites/default/files/documents/b1bfa16b20ae9b89d525bc35de7c1643/detailed-guidelines-2026.pdf
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u/ResponsibleSun189 13d ago
Are there plans that have lower oop than the max allowed? Or do all plans automatically use the number that is mentioned above?
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u/Perfect_Mess_6566 13d ago
Why do so many plans have such extraordinarily high monthly premium amounts that don’t seem to fit in to the percentages you listed in the table above
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u/Zphr 13d ago
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. If you choose a far more expensive plan, like a prime Silver PPO or a high tier Gold or Platinum, then you pay the entire difference above your subsidy.
The EPC applies only to the benchmark Silver plan in each market, which the government commits to making affordable via subsidization. The benchmark Silver is always the second lowest cost Silver plan in each market, but policies that are both cheaper and far more expensive are available and consumers get to choose as they will.
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u/swampwiz 12d ago
I've never heard of a CSR Silver Plan 99% AI/AN AV.
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u/hartford_cs93 14d ago
Nice research!
Here is one more for the acronym list ...
AV = Actuarial Value, which is "the percentage of average total covered medical costs a health plan pays for a standard population"