The 4 “Metal Plans” of Health Insurance Exchanges

Summary:  Do you know about the 4 most popular “Metal Plans” of Health Insurance Exchanges? What are metal plans? What distinguishes one from another? When do they go into effect?

Metal plans are the levels of plans that will be included in the health insurance exchanges. Health insurance exchanges are basically marketplaces designed for purchasing insurance. They are called metal plans because each level is a different metal: platinum, gold, silver, and bronze, and were created as a result of the Affordable Care Act. The idea for the metal plans originated in Massachusetts.

Open enrollment for the exchanges begins October 1, 2013, and coverage will be effective January 1, 2014. While each metal plan offers the same essential benefits, they will vary based upon premiums and out-of-pocket expenses. Out-of-pocket expenses include deductibles, copayments and coinsurance.

All health plans in the exchanges are required to provide a minimum set of benefits which are termed essential benefits. These benefits include:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health services
• Substance use disorder services
• Prescription drug coverage
• Rehabilitative and habilitative services and devices
• Preventative and wellness services
• Pediatric Services

4 “Metal Plans” of Health Insurance Exchanges

Platinum

• Lowest out of pocket for enrollees – approximately 10%
• Highest premiums

Gold

• Out of pocket expenses – approximately 20%
• Must be offered by an insurance company in order to participate in the exchanges

Silver

• Out of pocket expenses – approximately 30%
• Must be offered by an insurance company in order to participate in the exchanges
• The standard plan in terms of tax credit eligibility

Bronze

• Highest out of pocket expenses – approximately 40%
• Lowest premiums

The 4 “Metal Plans” of Health Insurance Exchanges

Within each of the different levels, premiums will vary depending upon which company insurance is purchased through. This is where the term marketplace comes into play. Consumers will have to shop around to find the plan that will best suit their needs in terms of out-of-pocket expenses, premiums charged, and whether their doctors are part of the particular network. Additionally, for those that opt not to have health insurance, there will be penalties assessed.  For 2014, the penalty will be the greater of $95 or 1% of adjusted annual household income. The penalties are expected to become steeper in later years.

Plans are beginning to release their premium schedules. They will vary from state to state. More detailed information will be released over the coming months so it will be important to remain current on the exchanges for your individual state.

About BHM Healthcare Solutions – www.bhmpc.com

BHM is a healthcare management consulting firm whose specialty is optimizing profitability while improving care in a variety of health care settings. BHM has worked both nationally and internationally with managed care organizations, providers, hospitals, and insurers. In addition to this BHM offers a wide breadth of services ranging including managed care consulting, strategic planning and organizational analysis, accreditation consulting, healthcare financial analysis, physician advisor/peer review, and organizational development.

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