Thousands of Marylanders Downgraded ACA Health Plans as Premiums Rose — What You Can Do About It

Rising ACA marketplace premiums are pushing households into a difficult choice: absorb a higher monthly cost, downgrade to a plan with steeper out-of-pocket exposure, or go without coverage entirely. In Maryland, thousands of residents made exactly that trade-off during recent enrollment periods, according to reporting from Maryland Matters. If you're facing the same pressure — in Maryland or any other state — understanding how ACA subsidies, plan tiers, and Medicaid eligibility interact may help you find coverage that fits your budget without leaving you exposed when you actually need care.

Data Snapshot

According to the U.S. Department of Health and Human Services (HHS), approximately 21.4 million people enrolled in ACA marketplace coverage for the 2024 plan year — a record high, driven largely by enhanced Premium Tax Credits first authorized under the American Rescue Plan Act and extended through the Inflation Reduction Act (source: HHS.gov ACA Enrollment Report). Despite that enrollment growth, average benchmark Silver plan premiums increased in many states for both 2024 and 2025, with some Maryland counties seeing double-digit percentage increases year over year. When premiums rise faster than subsidy adjustments, households near the upper edges of subsidy eligibility often face the steepest effective cost increases — which is the core driver behind the downgrade trend Maryland Matters documented.

For context: the 2024 Federal Poverty Level for a family of four is updated annually by HHS. Current FPL figures are available at Benefits.gov and your state marketplace. All eligibility thresholds in this article are expressed as percentages of FPL because the underlying dollar amounts change each year.

Why Premiums Are Rising — and Why Your Subsidy May Not Keep Pace

ACA marketplace premiums are set by private insurers and approved by state regulators on an annual basis. Several converging factors are pushing them higher: post-pandemic healthcare utilization catching up, rising prescription drug costs, and insurer recalibration after years of aggressive competitive pricing.

For consumers, a premium increase does not automatically mean your subsidy increases by the same amount. Here is the mechanic that matters: the Premium Tax Credit is calculated based on the cost of the second-lowest-cost Silver plan — called the benchmark plan — in your specific rating area. If your benchmark plan's premium rises, your subsidy may rise proportionally. But if you're enrolled in a different plan whose premium increased more steeply than the benchmark, you absorb that gap yourself.

This is why many Maryland enrollees — and consumers in other states — are moving to Bronze plans to keep monthly costs manageable. The trade-off is real: lower premiums, but higher deductibles and greater out-of-pocket exposure if you need care.

ACA Plan Tiers: What Changes When You Downgrade

Bronze Plans Bronze plans carry the lowest monthly premiums but the highest cost-sharing. Deductibles frequently range from $5,000 to $7,000 or more before coverage applies to most services. A Bronze plan may make sense for someone who is generally healthy and primarily wants financial protection against a catastrophic medical event — but it can be a costly choice for anyone who uses regular prescriptions, specialist visits, or ongoing treatment.

Silver Plans Silver plans are the only tier that qualifies for Cost-Sharing Reductions (CSRs). CSRs are a separate federal subsidy — layered on top of the Premium Tax Credit — that lowers your deductible, copays, and annual out-of-pocket maximum. They are available only to households with incomes between 100% and 250% FPL. If your income falls in that range, a Silver plan may cost you less in total annual spending than a Bronze plan, even if the monthly premium is higher. Running both scenarios side by side in your marketplace account is worth the time.

Gold and Platinum Plans These tiers carry higher monthly premiums but lower cost-sharing at the point of care. They may be worth comparing if you manage a chronic condition, take multiple prescriptions, or anticipate frequent medical visits.

Catastrophic Plans Available only to adults under 30 or those who qualify for a hardship exemption. Premiums are very low; deductibles are very high. Catastrophic plans generally do not qualify for Premium Tax Credits, which limits their usefulness for most subsidy-eligible households.

Who May Be Eligible for ACA Premium Tax Credits

Premium Tax Credits are available to households with incomes generally between 100% and 400% FPL. Under the enhanced subsidy structure currently in effect through 2025 (authorized by the Inflation Reduction Act), households above 400% FPL may also receive some subsidy if their benchmark premium would otherwise exceed 8.5% of their household income.

To potentially access Premium Tax Credits, you generally must: - Not have access to affordable employer-sponsored health coverage - Not be enrolled in Medicare or Medicaid - Be a U.S. citizen or lawfully present immigrant - File a federal income tax return for the coverage year (or plan to) - Enroll through your state's ACA marketplace, not directly through an insurer

Benefit amounts vary by household size, income, and the benchmark plan cost in your area. No specific dollar amounts can be guaranteed — use your marketplace's subsidy estimator for a personalized figure.

When Medicaid May Be the More Affordable Path

If your income has dropped — due to job loss, reduced hours, a change in household size, or other circumstances — a marketplace plan may not be your best or only option. Maryland has expanded Medicaid under the ACA, meaning adults with incomes up to 138% FPL may be eligible for Maryland Medical Assistance (the state's Medicaid program) at little or no monthly cost.

A critical distinction: Medicaid eligibility is based on current monthly income, not annual income. A recent income change could make you eligible right now, even if you would not have qualified earlier in the year. Medicaid has no enrollment window — you can apply any month of the year.

If you are currently enrolled in a marketplace plan and your income drops significantly, report the change to your marketplace account promptly. Depending on your updated income, you may be transitioned to Medicaid automatically, or you can apply directly through Maryland's Maryland Health Connection portal.

Step-by-Step: How to Review Your Coverage Options

Step 1: Estimate Your Household Income You will need an estimate of your household's Modified Adjusted Gross Income (MAGI) for the coverage year. This includes wages, self-employment income, Social Security benefits, unemployment compensation, and most other income sources. Use last year's tax return as a baseline, then adjust for any changes in employment, hours, or household composition.

Step 2: Log Into Your Marketplace Account Maryland residents use Maryland Health Connection. Residents in states using the federal marketplace use HealthCare.gov. Update your income and household information to generate an accurate subsidy estimate before comparing plans.

Step 3: Compare Plans Beyond the Premium The monthly premium is only one number. For each plan you're considering, also compare: - Annual deductible - Out-of-pocket maximum - Copays for primary care and specialist visits - Prescription drug formulary and tier structure - Whether your current providers are in-network

Step 4: Run the CSR Calculation If Your Income Is Below 250% FPL If your household income falls between 100% and 250% FPL, compare a Silver plan's total estimated annual cost — premium plus expected out-of-pocket — against a Bronze plan's. The CSR benefit can substantially reduce what you pay when you use care, sometimes making Silver the lower-cost option overall despite the higher premium.

Step 5: Get Free Enrollment Help Federally funded Navigators and Certified Application Counselors provide free, unbiased assistance with plan comparisons and enrollment. They do not earn commissions and have no financial stake in which plan you choose. Find one through LocalHelp.HealthCare.gov or Maryland Health Connection's navigator and broker finder. Maryland Health Connection also offers live chat and a phone support line during enrollment periods.

Documents to Have Ready

Gathering these before you start your application will reduce delays: - Social Security numbers for all household members applying for coverage - Employer and income information — recent pay stubs, W-2s, or a self-employment income estimate - Policy numbers for any current health insurance coverage - Immigration documents, if applicable

For Medicaid applications in Maryland, you may also need proof of Maryland residency, such as a utility bill, lease agreement, or bank statement showing a Maryland address.

Note: Submitting an application through Maryland Health Connection or HealthCare.gov may involve providing consent for the agency to verify your information with federal data sources. Review the consent language on any form before submitting.

Enrollment Timelines to Know

• Open Enrollment (November 1 – January 15 in most states): Plans selected by December 15 typically take effect January 1. Plans selected between December 16 and January 15 typically take effect February 1.
• Special Enrollment Period: Triggered by qualifying life events including job loss, marriage, birth or adoption of a child, or loss of other health coverage. You generally have 60 days from the qualifying event to select a new plan.
• Medicaid: Processed year-round with no enrollment window. Maryland typically processes standard Medicaid applications within 45 days; disability-based applications may take up to 90 days.

The Policy Context: Enhanced Subsidies Through 2025

The enhanced Premium Tax Credits that have kept marketplace coverage affordable for millions of Americans are currently authorized through the end of 2025. Whether Congress extends them beyond that point remains an open legislative question. If the enhanced credits expire without renewal, subsidy amounts would revert to pre-2021 levels for many households — meaning higher net premiums, particularly for people earning above 400% FPL who currently receive some subsidy.

If you are enrolled in a marketplace plan, staying informed about this policy timeline matters. CBPP.org publishes plain-language analyses of what subsidy changes would mean for low- and moderate-income households, and HHS.gov posts official enrollment and policy updates.

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Program eligibility and availability vary by state. Not affiliated with any government agency.

Last reviewed: July 2025