Four Metal health Care Marketplace Plans Under Affordable Care Act
Affordable Care Act seeks to provide quality insurance to those uninsured and those under insured. At the marketplace you can get low cost assistance, especially if your income places you below the 400% of the Federal Poverty Level. The Federal Poverty Level calculations for each state can be found at: http://aspe.hhs.gov/poverty/14poverty.cfm.
Note that under the Metal plans, the out-of-pocket payments can’t go over $ 6,350.00 for an individual and not over $ 12,700.00 for covering a family. All metal plans are HMOs.
In addition to the four plans, Bronze, Gold, Silver, and Platinum, people with hardship deemed exemptions could purchase what is called a “Catastrophic Health Plan.” This plan provides coverage for a low premium; however, the out-of-pocket expenses for medical care are high. Catastrophic Health plans are only available for people under age of 30.
The Affordable Care Act Four Metal Plans
Levels Cost Rank Out of Pocket % Plan Pays
Platinum Highest Lowest 90
Gold Higher Lower 80
Silver Moderate Moderate 70
Bronze Lower Higher 60
Catastrophic Lowest Highest Varies
Platinum Plans
Split Costs Covered 90/10
The Obama Care Platinum Plan offers to the consumer the lowest out-of-pocket payments with the maximum monthly health care insurance payment premiums. For those who want premium care for their family and can afford it and those who have family members who have frequent health cares services, the Platinum is the best choice. Note that with the premium plan, if your premium is capped, you will have to be responsible for making up the money gap difference.
Gold Plans
Split Costs Covered 80/20
The Obama Care Gold Plan is less expensive than the Platinum Plan. It has deductibles lower than the Silver Plan, but better sharing coverage for the consumer and his or her family. Keep in mind that two gold plans may have the same out-of-pocket expenses, but different insurance requirements and deductibles, since states offer plans from different companies.
Silver Plans
Split Costs Covered 70/30
The Silver Plan, considered the mean plan, is the one all other plans are actually based on. With the Silver Plan, you won’t have to pay more than 9.5% of your income if you bring home a salary less than 400% of the Federal Poverty Level. The less income that you make, then the lower your insurance premium will be. The Silver Plan is a great option for those people who have little to no serious health concerns, and use just a small amount of health care services.
Bronze Plans
Split Costs Covered 60/40
Bronze Health Care Plans are the least expensive of the Metal Plans. The insurers will pay only 60% of your covered care expenses. The consumer will pay the other 40% of the health care cost. This plan is the most limited as far as providers and services offered. It is an excellent plan for people who do not plan on using medical services or people who fall into the low-income bracket. Keep in mind, that even with the Bronze Plan, you will still get the ten Essential Benefits. The out-of-pocket costs will just be considerably more with the Bronze Health Care Plan.
Insurance Terminology
Navigating the Metal Plans will require you to be familiar with the insurance jargon and lingo. Use the following definition list to help you to understand the terms often used.
• Premiums – monthly or quarterly payments the consumer makes to the selected insurance company
• Benefits – the different services that offered to the consumer by the insurance company
• Out-of-Pocket Costs – any costs the consumer has to pay because they are not met by coverage through the designated insurance plan
• Premium Tax Subsidies and Cost-Sharing Reductions – additional benefits that the government may determine you/or your family are eligible to receive
• Medicare Supplement (often called Medigap) – additional coverage for the elderly or lower-income consumer not properly covered by traditional insurance
• Deductible – a set amount, which you will know upfront, that you must satisfy before your insurance begins to pay for health care costs
• Coinsurance – your share of the cost of a care or service. It is usually calculated as a percentage of the total cost of the medical service you received. You begin to pay coinsurance once your health care deductible has been satisfied.
• Copay -a fixed amount you pay for a medical service when you get the medical care
• HMO – (Health Maintenance Organizations)- a plan that may limit the specific providers (such as doctors) within a consumer’s network. A network includes the hospital, care center, and doctors listed for the specific plan. If you have a HMO, all Metal Plans are HMO, and you want to go to a doctor or medical provider outside of your network, you will have to pay the full cost of that visit or service. With a Health Maintenance Organization, to go to a specialty doctor such as a dermatologist, you have to get a referral from the primary care doctor that you designated when you took the plan.
• PPO – (Preferred Provider Organization)-You have more choices with the PPO. With a PPO, you can select caregivers from in or outside of your network. If you go outside of your network, you may have to pay a nominal fee. You can also visit specialty doctors, such as an allergist, without the need of a referral from a primary care giver.
• EPO – (Exclusive Provider Organization)- This plan is a slight hybrid of the HMO and the PPO.
You have to stay within your network for doctor choice or pay the extra fee, but you can go ahead and visit a specialist without getting or needing a referral from your designated primary provider.
You are the only one who can determine which plan offered by Affordable Care Act best suits you and your family’s needs. Do your homework before you decide on your plan and make sure you are aware of all terms, concepts, rules, and regulations of the plan that you ultimately select. The enrollment period is the only time when you can switch or change any part of your plan without a fee.
Remember, you need to be enrolled in the Marketplace to take advantage of the Metal plans by February 15, 2015. After that time, you may only enroll in emergency situations. If you miss the ACA open enrollment window, you will need to find outside coverage or be subject to the Affordable Care Act Penalty.