Here at Total Benefit Solutions Inc, we pride ourselves on helping Individuals choose a Health Plan that works for their Family and their budget. Choosing a health insurance plan can be complicated, which is why we recommend calling a Broker to help you choose a plan and step-by-step through enrollment. However, knowing just a few things before you compare plans can make the process simpler.
- The 4 “metal” categories: There are 4 categories of health insurance plans: Bronze, Silver, Gold, and Platinum. These categories show how you and your plan share costs. Plan categories have nothing to do with quality of care.
- Your total costs for health care: You pay a monthly bill to your insurance company (a “premium”), even if you don’t use medical services that month. You pay out-of-pocket costs, including a deductible, when you get care. It’s important to think about both kinds of costs when shopping for a plan.
- Plan and network types — HMO, PPO, POS, and EPO: Some plan types allow you to use almost any doctor or health care facility. Others limit your choices or charge you more if you use providers outside their network.
The ‘Metal’ Categories: Bronze, Silver, Gold & Platinum
FYI Metal categories are based on how you and your plan split the costs of your health care. They have nothing to do with quality of care.
How you and your insurance plan split costs
| Plan Category | The insurance company pays | You pay |
|---|---|---|
| Bronze | 60% | 40% |
| Silver | 70% | 30% |
| Gold | 80% | 20% |
| Platinum | 90% | 10% |
Which metal category is right for you?
Bronze
- Lowest monthly premium
- Highest costs when you need care
- Bronze plan deductibles can be thousands of dollars a year.
- Good choice if: You want a low-cost way to protect yourself from worst-case medical scenarios, like serious sickness or injury. Your monthly premium will be low, but you’ll have to pay for most routine care yourself.
Silver
- Moderate monthly premium
- Moderate costs when you need care
- Silver deductibles are usually lower than those of Bronze plans.
IMPORTANT:If you qualify for cost-sharing reductions you must pick a Silver plan to get the extra savings. You can save hundreds or even thousands of dollars per year if you use a lot of care.
- Good choice if: You qualify for “extra savings” — or, if not, if you’re willing to pay a slightly higher monthly premium than Bronze to have more of your routine care covered.
Gold
- High monthly premium
- Low costs when you need care
- Deductibles are usually low.
- Good choice if: You’re willing to pay more each month to have more costs covered when you get medical treatment. If you use a lot of care, a Gold plan could be a good value.
Platinum
- Highest monthly premium
- Lowest costs when you get care
- Deductibles are very low, meaning your plan starts paying its share earlier than for other categories of plans.
- Good choice if: You usually use a lot of care and are willing to pay a high monthly premium, knowing nearly all other costs will be covered.
Note: Plans in all categories provide free preventive care, and some offer selected free or discounted services before you meet your deductible.
Catastrophic Health Plans
Catastrophic health insurance plans have low monthly premiums and very high deductibles. They may be an affordable way to protect yourself from worst-case scenarios, like getting seriously sick or injured. But you pay most routine medical expenses yourself.
Who can buy a Catastrophic plan
Only the following people are eligible:
- People under 30
- People of any age with a hardship exemption or affordability exemption (based on Marketplace or job-based insurance being unaffordable)
If you’re eligible to buy a Catastrophic plan, you’ll see them displayed when you compare plans in the Marketplace.
How much Catastrophic plans cost
- Monthly premiums are usually low, but you can’t use a premium tax credit to reduce your cost. If you qualify for a premium tax credit based on your income, a Bronze or Silver plan is likely to be a better value. Be sure to compare.
- Deductibles are very high. For 2019, the deductible for all Catastrophic plans is $7,900. After you spend that much, your insurance company pays for all covered services, with no copayment or coinsurance.
What Catastrophic plans cover
- Catastrophic plans cover the same essential health benefits as other Marketplace plans.
- Like other plans, Catastrophic plans cover certain preventive services at no cost.
- They also cover at least 3 primary care visits per year before you’ve met your deductible.
Health Insurance Plan & Network Types: HMOs, PPOs, and more
There are different types of Marketplace health insurance plans designed to meet different needs. Some types of plans restrict your provider choices or encourage you to get care from the plan’s network of doctors, hospitals, pharmacies, and other medical service providers. Others pay a greater share of costs for providers outside the plan’s network.
Types of Marketplace plans
Depending on how many plans are offered in your area, you may find plans of all or any of these types at each metal level – Bronze, Silver, Gold, and Platinum. Some examples of plan types you’ll find in the Marketplace:
- Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).
- Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
- Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist.
- Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.
Your Total Costs for Healthcare: Premium, Deductible & Out-of-Pocket Costs
When choosing a plan, it’s a good idea to think about your total health care costs, not just the bill (the “premium”) you pay to your insurance company every month. Other amounts, sometimes called “out-of-pocket” costs, have a big impact on your total spending on health care – sometimes more than the premium itself.
Beyond your monthly premium: Deductible and out-of-pocket costs
- Deductible: How much you have to spend for covered health services before your insurance company pays anything (except free preventive services)
- Copayments and coinsurance: Payments you make each time you get a medical service after reaching your deductible
- Out-of-pocket maximum: The most you have to spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services.
How to estimate your yearly total costs of care
In order to pick a plan based on your total costs of care, you’ll need to estimate the medical services you’ll use for the year ahead. Of course it’s impossible to predict the exact amount. So think about how much care you usually use, or are likely to use.
- Before you compare plans when you’re logged in to HealthCare.gov or preview plans and prices before you log in, you can choose each family member’s expected medical use as low, medium, or high.
- When you view plans, you’ll see an estimate of your total costs — including monthly premiums and all out-of-pocket costs — based on your household’s expected use of care.
- Your actual expenses will vary, but the estimate is useful for comparing plans’ total impact on your household budget.
Total costs & “metal” categories
When you compare plans in the Marketplace, the plans appear in 4 “metal” categories: Bronze, Silver, Gold, and Platinum. The categories are based on how you and the health plan share the total costs of your care. Generally speaking, categories with higher premiums (Gold, Platinum) pay more of your total costs of health care. Categories with lower premiums (Bronze, Silver) pay less of your total costs. (But see the exception about Silver plans below.)
So how do you find a category that works for you?
- If you don’t expect to use regular medical services and don’t take regular prescriptions: You may want a Bronze plan. These plans can have very low monthly premiums, but have high deductibles and pay less of your costs when you need care.
- If you qualify for “cost-sharing reductions”: Silver plans may offer good value. If you qualify for extra savings (“cost-sharing reductions”) your deductible will be lower and you’ll pay less each time you get care. But you get these cost-sharing reductions ONLY if you enroll in Silver plan. If you don’t qualify for extra savings, compare premiums and out-of-pocket costs of Silver and Gold prices to find the right plan for you.
- If you expect a lot of doctor visits or need regular prescriptions: You may want a Gold plan or Platinum plan. These plans generally have higher monthly premiums but pay more of your costs when you need care.
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