Metal Plans Under the Affordable Care Act

The Affordable Care Act (ACA) created four new designs for health insurance policies. You may have heard policies referred to as “metal plans.”  This is because each design is named after a metal:

Bronze  |  Silver  |  Gold  |  Platinum

The four metal plans are distinguished from one another by their actuarial value.

Actuarial value (AV)  is the average amount of covered health care expenses that will be paid for by the insurance carrier.  It is also known as cost sharing.  The higher a plan’s AV, the greater the cost paid by the insurance company and the lower the out-of-pocket costs for the person covered.

Within the same insurance company, plans at the bronze level will have the lowest premiums, while plans at the platinum level will have the highest premiums.

However, it is possible, for example, for premiums charged by one company for its silver plan to be lower than the premiums charged by another company for its bronze plan.  That is why it is so important to fully understand the features of any plan you are considering.

Essential Health Benefits

All plans, regardless of their metal level, must cover ten essential health benefits.  Plans can offer additional benefits, but the basic, essential benefits must be covered.

Note, that’s not to say all of these benefits will be covered at 100%;  while certain preventive services must be covered at 100%, the portion of the expense paid by your policy for other essential services will depend upon the plan’s metal level as described above.

Here are the ten essential health benefits:

1. Ambulatory Patient Services — care you receive on a walk-in basis (e.g., doctor visits)
2. Emergency Services — care you receive at an Emergency Room
3. Hospitalization — medically necessary surgeries and other inpatient procedures
4. Maternity Care and Newborn Care
5. Mental Health Services and Substance Use Disorder Services — includes counseling and behavioral health treatment
6. Prescription Drug Coverage — prescription (but not over-the-counter) medications
7. Rehabilitative and Habilitative Services and Devices — examples are relearning to walk after a stroke (rehabilitative) or learning new skills like diabetes management (habilitative)
8. Lab Tests and Services — for example x-rays
9. Preventive and Wellness Services and Chronic Disease Management
10. Pediatric Medical Services (including both oral and vision care)

How Much Do the Metal Plans Cost?

Regardless of the metal level, health insurance premiums vary based upon:

• Your age
• Whether or not you smoke
• Where you live
• The number of people on your policy (e.g., family, individual, children, etc.)

Premiums cannot differ based on your health status or your gender.  In other words, you cannot be charged more if you have an existing medical problem, or based on your gender.

Since insurance carriers each set their own rates, it is always best to compare options available from more than one carrier.

All Health Insurance Premiums Include the Services of a Broker

That’s right.  It costs no more to use the services of a broker.  So, why not get the most for your premium dollars and let us help!   Virginia Medical Plans assists our clients in choosing the right coverage, enrolling in a plan, and handling administrative and claims issues for the life of their policy.

Call or email our office today!

• Phone:  1-800-867-0800
• Email: jkatz@vamedicalplans.com