Coverage Levels/Metal Tiers of health insurance in California
Covered California health insurance plans — and all health plans in the individual and small-group markets — are sold in four primary levels of coverage: Bronze, Silver, Gold and Platinum. As the metal category increases in value, so does the percentage of medical expenses that a health insurance plan covers, compared with what you are expected to pay in copay’s and deductibles. Plans in the higher metal tiers have higher monthly premiums, but you pay less when you need medical care. If you choose to pay a lower monthly premium, then you will pay more when you need medical care. You can choose the level of coverage that best meets your health needs and budget.
The breakdown of costs that you pay (dark shading) and costs the plan pays (lighter shading) for the standard Bronze, Silver, Gold and Platinum tiers is shown below.
Bronze: On average, your health plan pays 60 percent of your medical expenses, and you pay 40 percent.
Silver: On average, your health plan pays 70 percent of your medical expenses, and you pay 30 percent.In some cases, individuals may qualify for an Enhanced Silver plan. This means that when they choose a Silver plan, they have – based on their income – enhanced out-of-pocket savings through lower copays, coinsurance and deductibles. Individuals in these savings categories get the benefits of a Gold or Platinum plan for the price of a Silver plan. In the three categories of Enhanced Silver, the plan pays either 94 percent, 87 percent or 73 percent of expenses, with the enrollee responsible for the rest.
Gold: On average, your health plan pays 80 percent of your medical expenses, and you pay 20 percent.
Platinum: On average, your health plan pays 90 percent of your medical expenses, and you pay 10 percent.
In addition to the metal tiers, Covered California offers a minimum coverage plan for those who qualify.
Minimum coverage plan: If you’re under 30, you may be able to buy an additional health insurance plan option called minimum coverage plan. These plans usually have lower premiums and mostly protect you from worst-case scenarios. Minimum coverage plans through Covered California cover three doctor visits or urgent care visits, including outpatient mental health/substance use visits, with no out-of-pocket costs, and free preventive benefits. All other services will be full price but at the negotiated in-network price, until you spend $6,850, after which all in-network services are covered at 100 percent.
Essential Health Insurance Benefits
All health insurance plans now share some common characteristics. The Affordable Care Act requires that all health insurance plans offered in the individual and small-group markets must provide a comprehensive package of items and services, known as essential health benefits.
These benefits fit into the following 10 categories:
Ambulatory patient services.
Maternity and newborn care.
Mental health and substance use disorder services, including behavioral health treatment.
Prescription drugs. For more information about prescription drug benefits, visit the page Prescription Drugs.
Rehabilitative and habilitative services and devices.
Preventive and wellness services and chronic disease management. For more information about preventive services with no cost sharing, click here.
Pediatric services, including dental and vision care. Dental insurance for children will be included in the price of all health plans purchased in the exchange for 2015.
The requirement for insurance plans to offer essential health benefits is just one of many changes in health coverage that began in 2014.
* Very Important Homework Assignment!!
If you are in the process of choosing health insurance coverage and you like your current doctor. Ask them specifically what insurance they take both ON & OFF the Exchange??