Health Insurance Coverage Confusion

[Tyler54121]

Long time lurker here who has been able to do some serious damage to lowering costs. In fact, my wife and I just went down to 1 car since I now walk to work everyday! Thanks for all your help guys!

So, I am looking to buy health insurance for my wife since she will be losing her current coverage at the end of the year. She has a medical condition such that our current out of pocket expenses are over $100 per month with some great insurance coverage.

Looking at the ACA plans online (healthcare.gov), there are some plans that are quite cheap and have low out of pocket maximums. However, I am a bit confused as it seems too good to be true. For instance, one plan is $215 per month, but has an out of pocket maximum of $1,350 per year. We would probably hit that maximum in a year so that our medical cost would be $327.50 per month.

However, other plans that are higher "metal rating" include things such as this one with a "Gold" rating: $403 per month w/ out of pocket maximum of $6,000 per year. Doesn't this mean that, given our medical expenses out of pocket (assumed at $1,350 per year), would end up being much higher at $515.5 per month?

I feel that I must be missing something. . . Any help would be greatly appreciated!

[brewer12345]

I am going to guess that this is an artifact of the "cost sharing subsidy" which you are eligible for if you choose a Silver plan and have MAGI below a certain threshold (250%, IIRC).  Basically, if your income is pretty low you not only get a premium subsidy but you also get a subsidy that involves the feddle gubmint adding more money to the pot in order to lower some combination of your deductible, max OOP, copays, etc.  There is a sliding scale such that as your income goes down the subsidy goes up.  The catch is that you only get these goodies if you pick a Silver plan.  So if you pick a gold plan you only get the premium subsidy, not the cost sharing subsidy.

[Gimesalot]

One thing I have heard about the ACA plans is that the choice of doctors may be limited to lower price.  So maybe the Gold plan has a lot more doctors, hospitals, etc. in the program, whereas the lower cost plan has less options for care.