Marketplace premiums in New York: what affects price and how to compare plans

The 5 biggest drivers of premium differences

1. ZIP code / county: local plan competition and pricing vary.
2. Age: premiums generally rise with age.
3. Plan tier: Bronze/Silver/Gold changes premium vs deductible.
4. Network type: HMO/PPO-style networks affect price and access.
5. Plan design: deductible and out-of-pocket max drive total cost protection.

Premium vs deductible: what most people misunderstand

A lower premium often comes with a higher deductible. If you expect regular care, a slightly higher premium may reduce total yearly spending by lowering what you pay when you actually use care.

Bronze vs Silver vs Gold (plain comparison)

Network checks (don't skip)

One of the most common mistakes people make is choosing a plan based on price without checking the network. A low-premium plan is worthless if your doctors aren't covered. Here's what to verify:

• Primary care physician: Confirm your doctor is in-network. If you don't have one yet, check that the plan has PCPs accepting new patients in your area.
• Specialists you see regularly: If you have ongoing conditions, verify your specialists are covered.
• Hospitals: Check which hospitals are in-network, especially if you have a preferred facility.
• Prescriptions on the plan formulary: Even if a drug is covered, it may be on a high cost-sharing tier.
• Urgent care and ER coverage rules: Understand what happens if you need care away from home.

Understanding the True Cost of a Plan

Monthly premium is just one piece of the puzzle. To understand what a plan really costs, you need to think about total annual spending in different scenarios:

Pro Tip: For each plan you're considering, calculate all three scenarios. The "cheapest" Bronze plan may have the highest worst-case cost, making a Silver plan better overall protection.

HMO vs PPO vs EPO: What's the Difference?

Network type affects both your costs and your flexibility. Here's what each type means in New York:

Note: Not all plan types are available in all areas of New York. Availability depends on which insurers participate in your county.

Why Premiums Vary by ZIP Code in New York

You might be surprised to learn that two people in different parts of New York can pay very different premiums for the same plan tier. Here's why:

Age-Based Premium Variation

Under the ACA, insurers can charge older adults up to 3 times more than younger adults. This is called "age rating." Here's approximately how premiums scale with age:

Good news: Premium tax credits are calculated based on the benchmark plan cost for your age. So while older adults pay higher premiums, they also receive larger subsidies, making net out-of-pocket costs based on income rather than age.

Official Sources

Practical steps to compare plans

Here's a systematic approach to finding the right plan for your situation:

1. Shortlist 3-4 plans from different tiers (at least one Silver and one Bronze) that fit your budget.
2. Compare deductible and out-of-pocket max to understand your worst-case scenario. Calculate premium + OOP max for each plan.
3. Check the provider network for each plan. Your current doctors, preferred hospital, and any specialists you see regularly should be in-network.
4. Check prescriptions on each plan's formulary. Look at what tier your medications are on and what you'd pay per refill.
5. Consider your expected healthcare use for the coming year. Are you generally healthy? Planning surgery? Managing a chronic condition?
6. Decide based on total potential cost and risk tolerance. Some people prefer lower monthly costs with higher risk; others prefer predictable spending.

Related Resources

• Subsidy calculation examples →
• Income eligibility and limits →
• Health insurance cost overview →
• Health insurance glossary →