If you’ve been looking at signing up for a health plan for the first time, you’ll have noticed that all the plans are classified into one of four ‘metal’ tiers. These ACA health plan metallic levels may seem confusing at first glance, but once you know what they mean, they make understanding your options much easier.
Any health plan’s metallic level can influence its affordability and make it suitable or unsuitable for your healthcare needs. This is vital information for helping the uninsured population to find insurance that meets their needs.
Our guide to these metal tiers clearly explains what all the ACA health plan metallic levels are and what they mean for you.
Overview Of The ACA
Any discussion around healthcare and health insurance in the US will inevitably include reference to the ACA. The Affordable Care Act (ACA), or Obamacare, was signed into law by President Obama in 2010. It was the culmination of a long battle to reform healthcare in the US.
The Act and subsequent amendments have changed America’s healthcare and health insurance landscape. Healthcare is now more affordable and accessible than ever before, thanks to health insurance being more accessible and affordable.
The online ACA Marketplace features countless health plans offered by different insurers in various states. You’ll find several types of health insurance at various price points to suit most budgets.
The Metallic Levels Of The ACA
All ACA marketplace health insurance plans are categorized into four metal tiers – Bronze, Silver, Gold, and Platinum.
Do The Metal Tiers Offer Different Benefits?
The answer to this question is yes and no. Here’s why. All plans on all metal tiers must offer the same essential benefits, at minimum (listed below). However, some plans may offer extra benefits.
All ACA-compliant health insurance plans, regardless of metal tier, must offer policyholders a specific range of ten essential health benefits set out in the Act. In addition to this, all ACA marketplace plans must cover breastfeeding support, counseling, and breastfeeding equipment.
This applies to all metal tiers, but not to health plans initiated before the ACA came into effect (called ‘grandfathered plans’).
All ACA plans must also cover birth control services and counseling, as a health care provider prescribes. When provided by an in-network provider, these services are covered without a copayment or coinsurance, even if you still need to meet your deductible.
However, some plans offer additional benefits like dental and vision care for adults or specific medical management programs.
The Essential Health Benefits
These essential health benefits are available to every ACA policyholder, no matter the metallic level:
- Ambulatory patient services (outpatient care)
- Emergency services
- Hospitalization (including surgery and overnight stays)
- Lab services
- Mental health services, treatments for substance use, counseling, and psychotherapy
- Pediatric services, including children’s oral and vision care
- Pregnancy/maternity care and newborn care
- Prescription drugs
- Rehabilitative and habilitative services and devices (for injuries, disabilities, or chronic conditions)
- Preventive and wellness services ( including chronic disease management)
Features Of ACA Health Insurance Metallic Levels
There is much misunderstanding around the metal tiers on the ACA marketplace. Many people mistakenly assume that the tiers denote the quality of healthcare you’ll enjoy under these plans. This is not the case.
There are distinct differences between the metal tiers, but this has more to do with the various costs than the features.
The Bronze level is the lowest metal tier of the ACA health plans. Plans in this category have the lowest monthly premiums.
Unfortunately, this also means you must meet a higher deductible before medical services are covered. Higher out-of-pocket cost-sharing usually applies when receiving medical services after you reach the deductible.
These higher out-of-pocket costs may make a bronze plan unsuitable for people who need medical treatment often. But if you rarely need a doctor, the lower premiums generally make it affordable.
The insurer typically pays 60% of costs on Bronze plans, and the policyholder pays 40%.
- Lower premiums – most affordable of all tiers
- It may be suitable for people who rarely need healthcare services
- Higher deductibles than other tiers before coverage starts
- Higher out-of-pocket cost-sharing than different tiers after deductible reached
- It is not always suitable for people who need regular healthcare services
The Silver tier is only one level higher than the Bronze and, therefore, slightly more expensive. Silver plans offer a less restricted benefit design than Bronze plans, though.
The premiums are higher than the Bronze level but lower than the Gold and Platinum tiers. This makes it the second-most affordable category. The deductible and out-of-pocket costs are slightly less than for Bronze but higher than for Gold and Platinum plans.
The insurer typically pays 70% of the costs on Silver plans, and the policyholder pays 30%. However, cost-sharing reduction subsidies are available for Silver-tier benchmark plans.
Cost-sharing reduction (CSR) subsidies are a type of financial assistance available to eligible individuals and families. These subsidies aim to reduce out-of-pocket costs for low-income individuals and families, such as deductibles, copayments, and coinsurance.
- Lower premiums – second-most affordable of all tiers
- Slightly more coverage than bronze plans
- Cost-sharing subsidies available
- Generally, it has a higher deductible than the top two tiers before coverage starts
- Has higher out-of-pocket cost-sharing than the top two tiers after the deductible is reached
The Gold tier is the second-highest level of the ACA health plans and, therefore, has the second-highest monthly premiums. Gold plans offer more comprehensive health coverage but are less affordable than Bronze or Silver plans.
If you are in good health and don’t go to a doctor often, a Gold plan may not prove worthwhile because of those high monthly premiums. A Gold plan may be suitable for people who use healthcare services frequently due to its lower deductible and out-of-pocket costs.
The insurer typically pays 80% of the costs on Gold plans, and the policyholder pays 20%.
- Lower deductible and out-of-pocket cost-sharing than the Bronze and Silver tiers
- Suitable for people who receive regular healthcare services
- Higher monthly premiums than the Bronze and Silver tiers
- It is not suitable for people who rarely need healthcare services
As the highest metal tier, the Platinum level’s monthly cost is not affordable for most average Americans. It has the highest monthly premiums of the four levels. But it also offers the most comprehensive healthcare coverage of all the metallic levels.
A Platinum plan may not suit you if you rarely need medical care. That said, Platinum plans are ideal for people who need consistent medical care, as their deductibles and out-of-pocket cost-sharing are the lowest of all the tiers.
The insurer typically covers 90% of the costs on Platinum plans, and the policyholder pays only 10%.
- Lowest deductible and out-of-pocket cost-sharing of all the metal tiers
- The most suitable for people who regularly need medical care and health services
- Highest premiums of all the metal tiers
- The least suitable for people who rarely receive healthcare services
Subsidies And The Metal Levels
ACA subsidies are available to people who struggle to afford their health insurance. These subsidies are calculated according to total household net income. There are two types of subsidies – premium tax credits and cost-sharing reduction subsidies.
Premium tax credits are available across all metal tiers. You can receive this subsidy in two different ways. You can receive a tax credit when you submit your tax return. Alternatively, the credited amount can be paid directly to the insurance company, which will reduce the amount you pay monthly.
The other type of subsidy, the cost-sharing reduction one, is available only to those enrolled in a benchmark Silver plan.
Silver Level Cost-Sharing Subsidies
If you enroll in the benchmark Silver plan for your state but find it difficult to afford those out-of-pocket costs, you may be eligible for a cost-sharing subsidy.
You may apply for a subsidy on the ACA marketplace, where you sign up for your plan. However, as with the premium tax credit, eligibility for subsidies is not guaranteed. You will have to meet specific criteria, mostly income-related.
This subsidy offers help in various ways. You will have a lower deductible, pay less in copayments and coinsurance, and have a lower out-of-pocket maximum to reach.
Deciding Which Plan Is Best for You
With four metal tiers to choose from, how do you know which one is right for you? The secret is always to select a metal tier category aligned with your medical needs and budget. Afterward, you can narrow your search within that metallic level’s plans.
The Right ACA Health Plan Metal Level For Your Budget
Generally speaking, Bronze plans, with their lower premiums but higher deductibles and cost-sharing, are more suitable for individuals who don’t need regular medical care. Thanks to the lowest premiums of all the metal tiers, you’ll find this the most budget-friendly option.
Individuals who need more regular healthcare services may find Silver plans right for them. The monthly premiums are the second-lowest, and the deductible and cost-sharing are the second-highest, so occasional trips to the doctor should still be affordable.
Silver With A Subsidy
Individuals or, especially, families who need more regular healthcare or have affordability issues often select Silver with a subsidy. This can make a Silver plan as affordable as the Bronze level, in fact, even more so. Take note that cost-sharing reductions are only available for benchmark Silver plans. Premium tax credits are, however, available for all metallic levels.
The premiums may be the second-highest, but Gold plans have lower deductibles and out-of-pocket costs. So you’ll reach your deductible sooner, after which regular trips to the doctor will still be affordable. This makes a Gold plan suitable for individuals with high medical care needs, and families.
Platinum plans have the highest premium by far. However, their lower deductible and cost-sharing make them attractive to people who need frequent medical care. Those regular doctor visits will be more affordable than on a Bronze, Silver, or Gold plan (except in cases of Silver with a subsidy).
The ACA health plans’ metallic levels make choosing a plan easier. They indicate what you’ll be paying, both monthly and when you go for healthcare and medical services. However, your finances, as well as your unique medical needs, are the best guide of all.
Do you need assistance choosing the right metal tier plan for you? Enhance Health is the solution. Our consultants have the experience and expertise you need.
Contact us today to help you find the right metal tier for your needs.