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What is “actuarial value” for healthcare?

“To sum it up…”

  • Actuarial value is a method for assessing the value of benefits in a health insurance plan
  • Insurance plans offer benefits with costs sharing between the insurer and the insured persons
  • Actuarial value measures the amount of benefits with insurance coverage and the amount of funding the insurer provides to cover them
  • Obamacare set a minimum actuarial value for qualified health insurance plans

Actuarial value is a commonly used method for scoring the benefits of health insurance. It provides a common ground to compare the value of insurance to a policyholder in terms of the money provided by the insurance company and the money required from the consumer.

Actuarial value uses the total of payments from the insurance company for essential health benefits against the amount consumers must contribute for those benefits.

Comparison shopping is an ideal way to compare the benefits of health insurance policies. The true costs of health insurance go far beyond the price of premiums, and comparison shopping can reveal the actual costs.

Enter your zip code above to compare free health insurance quotes and discover policies that match your budget!

How Actuarial Value Predicts Costs


The Centers for Medicare and Medicaid oversees the Obamacare program. They needed a common method for comparing a wide variety of plans. The actuarial value was based on real-time consumer spending, and it predicted a consistent pattern of costs per user.

A Silver Obamacare plan pays 70 percent of covered benefits, and the consumer must pay the other 30 percent. The consumer’s share comes in several forms including deductibles, coinsurance, and copayments.

The actuarial value was developed by the CMS through a large survey of covered beneficiaries and the costs and charges they experienced. The CMS developed an actuarial value calculator.

Qualified Health Plans


The Affordable Care Act reformed health insurance practices for the benefit of consumers. Whether purchased on or off the Obamacare Marketplace, consumers would only get policies that provided qualified benefits with adequate limits.

Prior to the ACA, insurers frequently offered stripped down policies that would leave covered subscribers exposed to enormous costs as benefits disappeared due to annual or lifetime limits.

For example, the costs of outpatient care using medicines, tests, and laboratory procedures could fall upon an unsuspecting consumer with no insurance contribution by the device of annual or lifetime limits.

A baby born with a heart defect might use up its annual limit for intensive care in the first week of its life. Quality health plans forced insurers to provide meaningful protection that squared more faithfully with modern medicine and its costs.

Some Basics to Remember

  • Minimum Essential Coverage has an actuarial value of 60 percent, and the bronze plan is the lowest acceptable level of cost-sharing.
  • Essential Health Benefits are the key to quality coverage. These benefits must be covered by a minimum actuarial value if they would be sold on the Obamacare or state exchanges.
  • Minimum actuarial value must equal or exceed 60 percent. The insurance coverage must provide payments that on average cover 60 percent of the costs of covered benefits.

Networks and Expenses

Deductibles and other out-of-pocket costs can help consumers reach their expense limit.

At the point of exceeding the deductible limit, the insurance company must pay all of the costs of a covered benefit. This is a valuable situation for consumers that need moderate to heavy amounts of medical care and services.

Network resources count towards the limits of each plan; however, few plans permit outside services to count. The Obamacare rules do not count outside network services towards the plan’s limits or the overall limit.

Consumer Contributions and Actuarial Value


The stone in the pathway comes in the form of network restrictions. Some consumers lose the benefit of insurance cost-sharing payments completely when they must go outside of the plan’s network. In these cases, there are no protections from a potential mountain of medical debt despite full compliance with the payment and contribution terms of the policy.

Actuarial value proceeds on the idea that consumers will use services both inside and outside of the network as their random samples showed. In the current situation, consumer’s that opt to go outside their networks can incur a significant amount of medical expense debt.

– Deductibles

Health insurance deductibles are the payments required by the insurance contract before the insurance company pays its share of benefits. Generally, the lower the insurance premium, the higher the deductible.

Consumers rarely reach the deductible amount, and the insurance company pays nothing after collecting monthly premiums for a year. Selecting the right actuarial value to suit one’s needs is important.

Obamacare reforms offer no cost prevention and wellness services that include annual examinations, vaccines, and screenings. The prevention services have exceptional value to consumers.

Even without further insurance company contribution, these tests and screenings can detect diseases in early and treatable stages.

– Coinsurance and Copays


is the amount of the consumer’s contribution to the costs of a covered benefit. For example, the gold plans proved and an average of 80 percent insurance payments leaving twenty percent for consumer coinsurance.

Copays are small charges that consumers pay at the point of service for covered benefits.

Copays do not reflect the value of the service, and they are preset charges that improve insurance company profits by reducing their costs.

Some insurance advocates argue that co-pays help control the demand for services that might otherwise exceed the supply. While copays are generally small, the totals can add up to a substantial amount particularly for services that consumers frequently need such as office visits for consultation and follow-on care.

The CMS Sets Standards

The Centers for Medicare and Medicaid set standards for actuarial value in several steps. The first phase involved establishing clear information about the essential health benefits. In later developments, they provided calculators and instructions to state exchanges.

The minimum value permitted is that of a Bronze Obamacare plan. While bronze plans have a wide range of deductibles, network limitations, and copays, they all provide a 60 percent or higher level of insurance company costs sharing.

Rate Increases Made More Transparent

Actuarial value helps consumers understand the costs of coverage and the amount it increases from year-to-year. The Affordable Care Act enabled state regulators to ask more probing questions about increases and the reasons for them.

Actuarial value is an important tool for revealing costs and relating them to the public in a way that helps them compare and make wise selections.

Actuarial Value Helps Select High-Content Plans


The types of Obamacare plans offer a fine example of the use of actuarial value. Plans in the metallic tiers offer a conflicting degree of controls, network limitations, and deductible expenses.

The actuarial value common to each group gives consumers a logical place to start when making selections. The metal tiers of Platinum, Gold, Silver, and Bronze represent actuarial value groups.

The metal bands put plans together that have a similar range of covered benefits and cost-sharing.

Comparison shopping is a great way to discover which mix of services suits a consumer best. Each individual and family situation has priorities, and comparison shopping can focus on the features of greatest importance.

Enter your zip code below to compare free health insurance quotes that fit into your budget!

  1. https://www.healthcare.gov/glossary/actuarial-value/
  2. https://www.cms.gov/cciio/index.html
  3. https://obamacarefacts.com/insurance-exchange/qualified-health-plan/
  4. https://www.cms.gov/cciio/resources/data-resources/ehb.html
  5. https://obamacarefacts.com/health-insurance-networks/
  6. https://obamacarefacts.com/health-insurance/coinsurance/
  7. https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Review-of-Insurance-Rates.html