There are five levels of coverage in the marketplace. They are sometimes referred to as metal levels or levels of generosity. The levels are catastrophic, bronze, silver, gold, and platinum. Insurance companies are not obligated to offer plans in all five levels, but they must offer a silver and gold health plan in the marketplace. These metal levels classify plans based on the percentage of claims expected to be paid by the insurance company for that metal plan’s pool of insureds.

Plan Type

Average % of claim paid by insurer

Bronze plan

on average, 60% of claims paid by insurer

Silver plan

on average, 70% of claims paid by insurer

Gold plan

on average, 80% of claims paid by insurer

Platinum plan

on average, 90% of claims paid by insurer27

Keep in mind, that just because you have a silver plan, it does not mean that your plan will automatically pay 70% of your claim. The percentage is an actuarial estimate of the percentage that is expected to be covered for the general population in that metal level. For example, Bob has a Molina Healthcare of Florida Silver 250 plan, which has a deductible of $1700, an out of pocket maximum of $6,400, and a 30% coinsurance on hospital services. Bob had to go to the hospital a month ago and now has a $10,000 in hospital claims. Bob will end up paying $1,700 for his deductible, $2490 in co-insurance for a total of $4190. In this case, Bob’s silver plan only covered 58% of his claim, rather than the average of 70%. If Bob continues to have claims in the same calendar year, he could eventually reach his out of pocket maximum and all new claims would then be covered at 100%.

 

Catastrophic Plans

Catastrophic plans are offered in the Individual Marketplace and cover essential health benefits. Only individuals under age 30 and who do not have an affordable coverage option or who otherwise qualify for a hardship exemption to the minimum essential coverage rule are eligible. Catastrophic plans have higher deductibles than bronze, silver, gold, or platinum plans. Catastrophic plan enrollees are not eligible for the government subsidy.  However, catastrophic plans have several benefits. They offer lower premiums on average than bronze, silver, gold, or platinum plans. They also offer protection against out-of-pocket costs above $6350 ($12,700 for family). Additionally, they offer coverage of recommended preventative services without cost sharing.

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Michael Acosta

Michael.acosta@acostainsurance.com

305-265-8118

Posted 11:10 AM  View Comments

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