[PENNSYLVANIA] Why do some $0 marketplace health plans seem just as good as those costing $80+ per month?

I recently lost my job because my store shut down, and with it, I lost my health insurance. I don’t qualify for Medicaid because my unemployment benefits are too high. I was referred to Pennie, Pennsylvania’s health insurance marketplace, where I had to compare plans and choose one.

Here’s what confuses me: some of the $0 per month plans have similar or even better deductibles and out-of-pocket limits than plans that cost $100+ per month. I don’t understand the catch.

I go to the doctor about 15–16 times a year across two providers, so I need decent coverage. I picked a $0 plan for now, but I have 30 days to change it. How do I know if I made the right choice? What’s the difference between a $0 plan and a more expensive one? Any advice would be greatly appreciated!

The difference is likely in network size and prescription coverage.

Here are three things to check when choosing a plan:

  1. Cost: Can you afford the monthly premium and out-of-pocket costs?
  2. Coverage: Does it cover your medical needs and prescriptions?
  3. Network: Are your doctors in-network? Does the plan have a wide provider network in your area?

If the $0 plan meets all three criteria, then it could be a great choice for you.

@Sable
My prescriptions are covered, and one of my doctors isn’t listed in-network but said they accept my plan. My plan has a $1,200 deductible and a $3,050 max out-of-pocket limit. It’s called ‘Silver PPO Choice Select 1200/0/15 CSR87’—I don’t really know what that means. I picked it because it’s $0 per month, but similar plans are $100+.

Is there a reason this plan is free while others with similar numbers cost more? I might have to hire a broker to explain it, but I’d rather not spend extra money on that.

@Vaughn
The main differences between $0 and higher-cost plans usually come down to:

  1. Network Size: More expensive plans often have a wider network of doctors and hospitals.
  2. Prescription Coverage: Higher-cost plans may have better drug coverage with lower copays.
  3. Cost-Sharing Reductions (CSR): Since your plan has CSR87, you qualify for extra savings based on income. Only Silver plans offer CSRs, which lower your out-of-pocket costs.

Your plan details:

  • Silver = The tier of the plan (higher than Bronze, lower than Gold/Platinum)
  • PPO = Preferred Provider Organization (more flexibility than HMO)
  • 1200/0/15 = $1,200 deductible, 0% coinsurance, $15 copays for certain services
  • CSR87 = Cost-sharing reduction at the 87% level, meaning lower deductibles and copays

Just because a plan is free doesn’t mean it’s bad—it just means you’re getting a large subsidy due to your income.

@Sable
That makes sense, thanks! I also noticed that after enrolling, my plan says the actual premium is $595.30 per month, even though I was told it’s $0. And I see a tax credit of $650. What does that mean? Will I have to pay the full $595 later?

@Vaughn
No, you won’t have to pay that amount. The $595.30 is the full cost of your plan, but your tax credit covers the entire amount (plus some extra). So your out-of-pocket cost is still $0.

@Vaughn
The actual cost of your plan is $595.30 per month, but the government is covering it with a $650 tax credit, so you owe nothing.

This is normal for marketplace plans—many people get subsidies based on income. Just make sure to update your income if it changes, because if you start earning more and don’t report it, you might have to pay some of the subsidy back at tax time.

I’ve seen this too. My husband and I have different Silver plans through BCBS. His plan is $0 per month, while mine is $28. They’re very similar, but the biggest difference is in prescription coverage—my plan covers generics for free, while his has a 20% charge for prescriptions.