When shopping on the Health Insurance Marketplace, you will notice that every tier has a corresponding “metal” — Platinum, Gold, Silver, and Bronze. All policies on both federal and state-run marketplaces are categorized using these metals. These tiers give you a quick idea of how much the plan will cost you in monthly premiums and out-of-pocket costs. These metal tiers do not reflect the kind or quality of service you may receive. However, the metal types communicate other essential plan details.
Health Insurance Metal Levels At a Glance
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What is the Bronze Level?
Bronze plans typically cover 60% of covered healthcare expenditures, which means enrollees pay the remaining 40% out of pocket. These plans have the most affordable monthly premiums among all metal tiers. However, if you require medical attention, you pay more for services than other tiers. Bronze plans also often have the highest deductibles, which means enrollees must pay more out of pocket before their plan’s cost-sharing kicks in.
For those seeking the most affordable way to obtain coverage, Bronze plans are the best option. However, because you pay a larger percentage of your health bills, costs can be high if you need major or recurring medical attention. For this reason, Bronze plans are best suited for healthy people who are unlikely to need major medical attention.
What is the Silver Level?
Under Silver plans, consumers are often responsible for 30% of their medical costs, while the insurance company typically takes care of the remaining 70% of covered services. Generally, Silver plans feature moderate monthly premiums and provide clients with moderate rates for medical treatment. Deductibles are also lower with these plans than with Bronze plans. Those enrolled in Silver plans may be eligible for additional savings, or cost-sharing reductions, based on family size and income level.
Though it has higher premiums than a Bronze plan, Silver plans are usually a good option if you have recurring health needs and prescriptions or anticipate using your health insurance policy regularly.
What Is a Cost-sharing Reduction (CSR)?
With a cost-sharing reduction (CSR), you receive a discount that reduces the amount you are responsible for paying in copayments, deductibles, and coinsurance. If you are eligible, you can save money by using less of your own funds each time you need medical care. CSRs are based on your state, income, and family size, and they only apply to Silver plans.
Your CSR eligibility is automatically calculated when you enroll in a Silver plan. If you lose your CSR, you will be eligible for a Special Enrollment Period. This allows you to select a new plan that fits your budget and healthcare needs outside of the Open Enrollment Period.
What is the Gold Level?
Gold plans tend to take care of 80% of covered healthcare costs, meaning enrollees have to pay the remaining 20% out of pocket. These plans feature more expensive monthly premiums but more affordable healthcare visits. Typically, their deductibles are relatively low, so your insurance’s cost-sharing starts much sooner.
Gold plans are best for those who tend to receive frequent medical care each year. Though the monthly premium to keep coverage active is higher than with Silver and Bronze plans, Gold plans can help make healthcare more cost-effective in the long run through lower deductibles, copays, and coinsurance rates per doctor’s visit and pharmacy refill.
What is the Platinum Level?
Patients are usually only responsible for 10% of their medical costs with Platinum plans, which typically means the plan will pay for 90% of covered healthcare expenses. These plans come with the most expensive monthly premiums, but enrollees pay the least for every healthcare service. Platinum plans have the lowest deductibles of all the metal categories, so they kick in the fastest to help pay for covered benefits.
A Platinum plan can be the best option for those requiring frequent doctor’s visits and multiple prescriptions, as the plan would cover most of those costs. Despite having the highest monthly premium of all the metal tiers, the reduced cost for overall care could help those with recurring needs save on healthcare expenses.
What Are Catastrophic Plans?
Catastrophic plans provide people who rarely need healthcare a way to protect themselves if something major happens, such as injuries from an accident or a sudden serious illness. They also help offset the costs of some preventative healthcare, such as getting up to three checkups with your primary care doctor each year.
These plans have low monthly premiums, making them more affordable for those on a tighter budget, but they also have very high deductibles and little cost-sharing with the insurer. This means you will be responsible for paying for most of your care out of pocket if you suffer from a catastrophic illness or injury.
These plans are more suitable for younger people who generally have good health. This is because a catastrophic plan covers the kinds of routine checkups younger people need as well as sudden emergency medical costs. To be eligible for this type of plan, you must be under 30 years old or qualify for a special hardship or affordability exemption.
Mandatory Health Insurance Marketplace Coverages
Consumers can use a health insurance marketplace to acquire health insurance policies and obtain income-based subsidies to lower the cost of coverage and care. In most states, consumers use the federal Health Insurance Marketplace. However, several states have their own platforms, such as Connect for Health in Colorado, Covered California in California, and New York State of Health for New York.
The most significant difference between state-based and government-run marketplaces is that in state-based systems, the state controls the insurance administration. This means that the enrollment process may vary significantly among states that use a state-based marketplace.
However, whether a state uses its own marketplace or the federal exchange, every health insurance plan offered on the marketplace must cover 10 essential health services:
- Ambulatory patient services: This includes the cost of patients being transferred in an ambulance to healthcare facilities from their homes or other points of origin.
- Emergency services: These include the vast range of healthcare needs that require patients to go to an emergency room.
- Hospitalization: This refers to when a patient has to stay in a hospital for any extended period.
- Laboratory services: Lab services cover a wide range of tests and scans that help healthcare providers understand how to treat patients.
- Mental health and substance use disorder services: These services provide care for patients experiencing mental health issues, as well as those dealing with drug or alcohol abuse.
- Pregnancy, maternity, and newborn care: These services encompass the care that mothers and their children need before, during, and after the child is born.
- Prescription medications: Prescription coverage handles the cost of medication that’s prescribed by doctors as part of a treatment process.
- Preventive and wellness services and chronic disease management: This includes services that help patients maintain and improve their health and sustain a higher quality of life if they have a chronic disease.
- Pediatric services: These cover any health services that support babies and children.
- Rehabilitative and habilitative services: Rehab services help people recover from diseases, injuries, or surgeries. Habilitative services provide care and support for children born with genetic conditions.
Health Insurance Subsidy Options
A health insurance subsidy reduces the cost of healthcare for people with eligible incomes. The two main types of subsidies are Advanced Premium Tax Credits (APTCs) and cost-sharing reductions (CSRs). APTCs can be applied to any metal tier plans, unlike CSRs, which can only be used for those enrolled in Silver plans.
Subsidies lower your monthly premiums and other costs because the government covers some or all of your healthcare expenses. They are only available if you have purchased a plan through your state’s insurance marketplace or the federal marketplace.
What is an Advanced Premium Tax Credit (APTC)?
An Advanced Premium Tax Credit (APTC) is a credit you can take on your taxes to reduce your monthly health insurance premium. Unlike cost-sharing reductions (CSRs), you do not have to enroll in a Silver plan to receive the APTC. Eligibility is determined when you estimate your annual income after applying for a Marketplace health insurance plan. If your yearly household income is between 100% and 400% of the federal poverty level and you do not receive government-paid coverage such as Medicaid or affordable coverage through an employer, you are generally eligible for the APTC.
If you receive the APTC, you can choose to have the payment made directly to your insurance company to lower your monthly payment. Note that if you end up qualifying for a lower tax credit at the end of the year, you must repay the difference.