Quick answer
For ACA-compliant individual and small-group plans, insurers can set your premium using only five things: your age, where you live, tobacco use, how many people are covered and the plan level. Your health, sex, weight, job, marital status and medical history can’t be used. Behind those five factors, each insurer’s base rate reflects local medical prices, its network, the health of its members and its costs, which is why prices differ between companies.
Key takeaways
- Older adults can be charged up to 3 times as much as younger adults for the same plan.
- Tobacco users can be charged up to 50% more, and premium tax credits don’t cover the extra.
- Pre-existing conditions, sex, weight and family medical history can’t raise an ACA premium.
- Insurers must spend at least 80% of individual-market premiums on care and quality, or pay rebates.
- What you actually pay also depends on your income, through premium tax credits.
On this page
The five factors ACA plans can use
| Factor | How it works |
|---|---|
| Age | Adults 64 and older can pay up to 3 times what a 21-year-old pays. A 40-year-old pays about 1.28 times as much, and children under 15 about 0.77 times |
| Location | Prices are set by rating area, usually a group of counties, and reflect local medical costs |
| Tobacco use | Insurers can charge up to 50% more. Some states ban or limit the surcharge |
| Who’s covered | Each person on the plan adds a premium, but no more than three children under 21 are charged |
| Plan level | Bronze costs least and platinum most, because the plan pays a bigger share of your care |
For example, if a 21-year-old pays $400 a month for a plan, a 40-year-old would pay about $511 and a 64-year-old about $1,200 for the same plan. That’s why older adults often pay the most before subsidies.
What can’t affect your ACA premium
| Factor | Can it raise your ACA premium? |
|---|---|
| Pre-existing conditions or medical history | No. See getting health insurance with pre-existing conditions |
| Sex | No. Women can’t be charged more, and maternity care is a covered benefit |
| Weight | No. Some job-based wellness programs offer rewards, and some plans cover weight-loss programs |
| Genetic information and family history | No. Federal law bars health insurers from using it |
| Occupation | No |
| Marital status | No, though adding a spouse adds a premium. See can a spouse be dropped from health insurance |
| Past gaps in coverage | No |
A condition like diabetes doesn’t change what an ACA plan charges you, though it will affect how much care you use.
Tobacco use
Insurers decide how large a tobacco surcharge to charge, up to 50%. Tobacco use usually means using tobacco four or more times a week in the past six months. Premium tax credits don’t cover the surcharge, so it comes straight out of your pocket. See does smoking affect your health insurance rates and what happens if you start smoking.
How insurers set their base rates
Each year, insurers file proposed rates with state regulators. The rates reflect:
- Local prices for hospitals, doctors and drugs. Prices vary a lot from city to city.
- The network. Plans with broad networks or expensive hospitals usually cost more. Care outside the network costs more still; see what to do about out-of-network costs.
- How much care members use, including prescription drugs.
- Plan design, including copays and coinsurance.
- Administrative costs, taxes and profit. In the individual and small-group markets, insurers must spend at least 80% of premiums on medical care and quality improvement (85% for large groups) or send rebates.
For 2027, insurers proposed a median increase of 15%. They pointed to rising medical costs, higher payments to hospitals and doctors, costly drugs like GLP-1s, and healthier people dropping coverage after the enhanced premium tax credits expired.
What you pay after subsidies
If your household income is between 100% and 400% of the federal poverty level, a premium tax credit caps what you pay for the benchmark silver plan at a share of your income, so your age and location matter less. Rates also differ from one company to the next; compare the best health insurance companies in your area, and see how to switch health insurance companies if you find a better deal.
Job-based plans
Large employers’ premiums can reflect their own workers’ claims, and the employer decides how much of the premium you pay. Job-based wellness programs can offer rewards worth up to 30% of the cost of coverage, or up to 50% for programs to stop using tobacco.
Related guides: 2027 premium increases by state, health insurance for a 40-year-old and health insurance for a 60-year-old.
See what plans cost for your age and ZIP code: compare quotes.
Frequently asked questions
Do pre-existing conditions raise health insurance rates?
Not on ACA-compliant plans. Insurers can’t charge you more or deny you because of your health.
Why do older people pay more for health insurance?
Older adults use more care on average, and the ACA lets insurers charge adults up to 3 times more based on age. Premium tax credits offset much of that for people who qualify.
Do women pay more for health insurance?
No. ACA plans can’t charge different premiums based on sex.
Does my credit score affect my health insurance rate?
No. Health insurers can’t use it to price ACA plans.
Sources
This article is general information, not insurance advice. Rating rules can vary by state. Last reviewed September 2026.