Choosing from hundreds of plans can be intimidating to say the least.  The first thing we tell our clients even before we go through the subsidy application (to determine how much money is available to help you pay for your health insurance) is simply not to stress.  Remember you are purchasing MAJOR MEDICAL INSURANCE and although there are differences between each of the categories,  no matter which plan you  pick, all policies have built-in protections which make them indispensable in the event of a major or chronic illness.   Another important feature of the law is your right to change plans every year regardless of pre-existing conditions.  If you decide to purchase a less expensive policy this year and next year you require a different set of benefits, you are no longer bound to any pre-existing condition clauses which held consumers hostage in the past. That is a GOOD thing.

Should you pick a bronze, silver, gold or platinum plan?   There is not a “one size fits all” answer.

BRONZE:

PRICE ☺ ☺ ☺ ☺ ☺

MAJOR MEDICAL and CATASTROPHIC COVERAGE ☺ ☺ ☺ ☺ ☺

CO-INSURANCE ☺ ☺

PREVENTIVE ☺ ☺ ☺ ☺ ☺

DAY TO DAY COSTS TO CONSUMER ☺

Bronze is the least expensive of the metallic levels.  The premiums are lower for a number of reasons:

1. It has the highest co-insurance percentage – 60/40%.  Co-insurance is the percentage of the approved billing that you are responsible for after you meet your deductible.  In many cases under the bronze category, the deductible is equal to the out of pocket maximum, meaning that after you meet the deductible there are no additional charges.  The highest deductible and or out of pocket maximum for a bronze is $6600.00 for an individual and $13,200 for a family for in-network services.
2. Notwithstanding the above, your preventive care is AT NO COST. Many carriers also cover your primary care doctors with a co-payment.  Look closely at the benefits because the majority will expose the deductible on all services except your preventive care.

SILVER:

PRICE ☺ ☺ ☺ ☺

MAJOR MEDICAL and CATASTROPHIC COVERAGE ☺ ☺ ☺ ☺ ☺

CO-INSURANCE ☺ ☺ ☺

PREVENTIVE ☺ ☺ ☺ ☺ ☺

DAY TO DAY COSTS TO CONSUMER ☺ ☺ ☺

Silver is the most unique of the metallic levels because if your income is within 101-250% of the federal poverty line in a non-expansion Medicaid state, and between 139%-250% in a Medicaid expanded state, the carriers under the law offer benefits under a cost share provision.  Cost share will lower deductibles, out of pocket maximums, co-insurance, and co-pays to assist the consumer with their healthcare expenses.

1. If you don’t have cost share Silver plans will generally have a co-insurance percentage of 70-30%, meaning that services where the deductible is exposed, you would pay the negotiated rate until your deductible is exhausted and after that you would pay 30% of any additional costs until you reach your out of pocket maximum for the year.
2. Your preventive is covered at no cost.
3. Your primary and specialists for the majority of carriers will have a set co-payment.
4. Most will cover emergency room visits with a co-pay (no deductible)
5. Depending on the carrier, simple diagnostics, imaging and lab work will also be covered with a co-payment.

GOLD AND PLATINUM

PRICE ☺

MAJOR MEDICAL and CATASTROPHIC COVERAGE ☺ ☺ ☺ ☺ ☺

CO-INSURANCE ☺ ☺ ☺ ☺ ☺

PREVENTIVE ☺ ☺ ☺ ☺ ☺

DAY TO DAY COSTS TO CONSUMER ☺ ☺ ☺ ☺ ☺

1. Gold and Platinum plans have the highest premiums based on their co-insurance levels, 80/20 and 90/10 respectively. In each case and on deductible exposed procedures or services, you would pay negotiated network rates until you meet the deductible and then pay either 20% or 10% of the invoice until you meet the out of pocket maximum for the calendar year.  Gold and Platinum plans generally have lower deductibles and out of pocket maximums as well.  Regarding benefits for day to day usage, it is similar to the Silver category.
2. Your preventive is covered at no cost.
3. Your primary and specialists for the majority of carriers will have a set co-payment.
4. Most will cover emergency room visits with a co-pay (no deductible)
5. Depending on the carrier, simple diagnostics, imaging and lab work will also be covered with a co-payment.

In summary:

1. If you are receiving cost share Silver is your best choice. Cost share reduces your deductible, out of pocket maximums, co-insurance, and co-pays.  You can’t go wrong with that. You might save a few dollars going with a Bronze plan and unless an economic necessity, NOT WORTH IT.
2. If you are not receiving cost share and are healthy, Bronze is the way to go as you will save the most with your premiums, and remember: included is your free preventive for the year and in the event of a catastrophic or chronic illness YOU HAVE MAJOR MEDICAL INSURANCE.
3. Gold and Platinum plans are a good choice when you are managing a chronic illness and require a health insurance plan with lower co-insurance. They are also usually good choices for young professionals as rates in many instances are not dramatically different to a silver plan, however those differences are significant if you are middle aged.