Gold, silver and bronze are familiar categories for fans of the Olympic Games, but before the advent of the Affordable Care Act (ACA) in 2009, it was unlikely that many Americans associated those metals with health insurance.
“The terms bronze, silver, gold and platinum are part of a new era of health insurance comparison shopping,” says Adam Pittler, director of Product Development of UPMC Health Plan. “These metallic levels have been designed to help persons purchasing health insurance by providing more information.”
The Open Enrollment period for ACA coverage in 2016 that began Nov. 1, 2015, ends Jan. 31, 2016.
Smart Business spoke with Pittler about the “metallics” and how they can impact health insurance decisions in the years ahead.
Why do plans on the ACA Marketplace use the metallic terms?
The metal tiers are in place to provide consumers with a standard measurement to make it easier to compare plans and to understand which plans offer more comprehensive coverage and cover a greater portion of health care costs.
Plans in each category are assigned what is referred to as an ‘actuarial value.’ That refers to the share of health care expenses that the specific plan will cover.
If, for instance, you decide to purchase a bronze plan you will need to pay the most out of pocket. The plans are rated up from there — silver, gold and platinum, the highest. Platinum plans are the most generous and carry the highest premiums, but also have the lowest out-of-pocket costs. For example, a bronze plan will cover 60 percent of health care costs, a silver plan will cover 70 percent, a gold plan 80 percent and a platinum plan will cover 90 percent.
It’s important to remember that the metallic categories do not correspond to the amount or to the quality of care that you get with that plan.
Do the plans have any similarities?
All plans — bronze, silver, gold and platinum — must provide a minimum level of coverage in 10 categories, which are known as essential health benefits. These include prevention and wellness, ambulatory (outpatient) care, laboratory services, emergency care, hospitalization, maternity and newborn care, pediatric care (medical, dental and vision), mental health and substance use disorder services, prescription medications, rehabilitation and habilitation.
So, it doesn’t matter which metallic level you choose, all plans are guaranteed to provide at least this level of benefits.
How do you evaluate plans on the same metallic level?
You need to carefully review the details of each health insurance plan that is offered at that level. This includes the cost of monthly premiums, deductibles, copayments and coinsurance. All insurers are required to provide an easy-to-read summary of benefits and coverage to help compare plans.
Even though two plans might be on the same level, the cost to an individual consumer may differ. This could be because of out-of-pocket expenses that are accrued and are dependent on the health services needed.
What about tax credits?
Consumers looking to maximize tax credits and subsidies should probably look to silver level plans. The sizes of the tax credits are based on income level and the cost of the second-lowest silver plan in each region. The tax credit remains the same for all levels. So, it covers more of the premium at a silver level than it does at the gold and platinum levels.
Persons who are entitled to subsidies need to enroll in a specific silver plan in order to receive it.
How important is it to estimate costs?
Most insurance purchasers are focused totally on the cost of the premium and do not think about what their estimated total health care costs could be for an entire year. That means trying to make an estimate of what your out-of-pocket liability will be.
You have to determine if a higher monthly premium would be worth it in order to decrease out-of-pocket expenses.
Insights Health Care is brought to you by UPMC Health Plan
