Can I Reduce My Premium and Out-of-Pocket Costs on the Marketplace?

Costs continue to increase for everything from a loaf of bread to housing and, yes, health insurance. Thanks to federal regulations you have options to keep costs low month-to-month. Here’s a breakdown of cost considerations for individual and family plans on the Health Insurance Marketplace from Kate Serenbetz, Individual Product Manager for Avera Health Plans.

“Savings come in many ways for health insurance whether you’re eligible for federal cost reductions or using your benefits to the highest advantage,” Serenbetz said. “It adds up over time.”

Does Your Income Allow for Tax Credit Savings?

The biggest opportunity for savings is through premium tax credits. Many people think they make too much for tax credit savings, but that usually isn’t the case.

In South Dakota, many Marketplace enrollees save from advance premium tax credits. This brings the cost from an average premium in the state of $695 a month to $114, according to data from the Centers for Medicare and Medicaid Services (CMS).

• 36% of South Dakota enrollees had a premium of $10 or less
• $92 a month average premium for those enrolled in the tax credit program

“Even if you think you won’t meet the requirements, take the time to see,” Serenbetz said. “It could save you hundreds a month and with our easy quote process it just takes a few minutes.”

Changes to Premium Tax Credits in 2026

Be ready for this program to change in when you consider plans for 2026. Congress has not extended the enhanced premium tax credits that were introduced during the COVID-19 pandemic. Premium tax credits will still be offered to qualifying health insurance buyers, but the amount of premium assistance will revert to pre-COVID lower levels. This means that most enrollees will see increases in premiums.

“These changes are universal for policies sold by all insurance companies on the Marketplace,” Serenbetz said. “If your premium is going up with your current plan, it will also be higher with another health insurance carrier.”

She recommends people look at different plan options that can ensure coverage.“If you had a Silver plan and can’t afford the higher premium, you can look into a Bronze plan or a plan with a higher deductible.”

Read more: What to know about changes to health insurance in 2026

What About My Deductible, Co-Pays and Coinsurance?

Out-of-pocket expenses can add up, especially if you have a chronic illness or a major injury. You can also apply for cost share reductions, which reduce out-of-pocket costs as long as you use a covered health care service and have a silver plan. Eligibility is based on household income, and 37% of Marketplace members in South Dakota are eligible for these savings, according to the CMS data.

Your payments are decided on a sliding scale. For instance, if your household income is 100 to 250% the federal poverty level, the reduction is 95%. That means you’ll pay 5% of your deductible, co-pay or coinsurance.

What Type of Plan Is Right?

The type of plan is key for monthly expenses. Choose a plan that balances what type of care you need with the cost. Keep this in mind:

• The higher your premium, the lower your out-of-pocket costs – and vice versa.

If you don’t go to the doctor a lot, a high deductible health plan could be a great option.

• Your network of providers can also affect cost. A more direct network, based on a specific region, can help keep your premium down.

Our Direct plan options are available in Brown, Lincoln and Minnehaha counties and include the Avera Health system of providers.

Long-Term Cost Savings

Beyond these major savings opportunities, using your benefits can also provide savings in the long run.

Pharmacy Formulary

You probably know that generic drugs are cheaper than the brand name options. But costs can also vary in other ways. That’s why a pharmacy benefits manager can be an important part of your health plan selection as a partner in offering cost comparison.

This could help you determine if a different pharmacy or prescription may offer a lower price, or an online option such as Amazon Pharmacy. Avera Health Plans Rx includes more than 56,000 pharmacies, including Avera Pharmacy and other local options.

Preventive Care

Preventive care is covered as part of all ACA plans. This includes a yearly checkup along with many screenings such as mammogram and colonoscopy.

But does your plan offer more than this? For instance, some Direct plans offer five visits a year with $0 co-pays, beyond primary care – chiropractic, behavioral health and rehabilitation visits.

Wellness Incentives

Does your plan have any wellness benefits to keep you healthy or help you get back on track? It may seem like a small amount, but a gym reimbursement can add up over time, especially if you’d get it anyway. Consider these offerings and be sure to make use of them. You may also have access to other programs that help manage chronic conditions. Consider Avera Health Plans offerings:

• ActiveLife, our fitness center reimbursement program
• Virta, a health coaching program for people diagnosed with obeseity, prediabetes and type 2 diabetes
• MyWeighForward plan options, which may cover popular weight loss medications

“A little research can go a long way when understanding your health insurance options,” Serenbetz said. “Your plan covers so much more than a clinic visit.”