Health insurance plans are contracts between an insurer and an individual or family to cover their medical expenses. They can either be private or government-sponsored.
There are various health insurance plans, each tailored to a different set of needs. It’s essential that you comprehend how these programs function so that you can select the most suitable option for you.
What is health insurance?
Health insurance is an option that helps cover medical care costs when you become ill or injured. It may also cover prescription drugs and other healthcare-related expenses.
Health insurance comes in many forms. Government programs like Medicare and Medicaid (which offer subsidized coverage to the elderly, disabled and children) are two examples; alternatively, some policies are private.
Individual and family health plans are the most popular types of coverage. They can be acquired through an employer, the federal or state Health Insurance Marketplace, a broker or navigator, or directly from insurance companies.
In exchange for paying a monthly premium, health insurers agree to cover part of the cost of covered medical services. These are known as ‘covered benefits’ and may include doctor’s visits, hospitalization, lab tests and other diagnostic procedures.
Health insurers typically pay for services based on discounts they’ve negotiated with doctors and hospitals, which can be a fraction of what the provider would charge you without the discount.
Another popular way health insurers reduce the cost of coverage is by offering in-network services. This means the health insurer has preselected certain healthcare providers as ‘in network’ and will pay them discounted copayments or deductibles for services they provide to plan members.
Selecting the correct type of insurance is a critical decision that can have an immense impact on the cost of care. If you want to get a low-cost, high-quality plan, it’s essential to research all available options and consult with a reputable health insurance agent about them. They will assist in selecting the most suitable solution for both your needs and budget.
Bronze plans are one of four “metal tiers” available to individuals on the Health Insurance Marketplace (also referred to as an Exchange). These tiers are determined by how much you and your health plan contribute towards healthcare costs.
Bronze plans offer a lower monthly premium than silver or gold plans, but your out-of-pocket expenses may be higher. That being said, bronze plans may be suitable for healthy individuals who do not anticipate using their insurance often.
If you have a low income, cost-sharing reductions may be available to make your deductibles, copays and coinsurance cheaper. These subsidies can significantly reduce the amount of money paid for monthly premiums on bronze plans; making them an excellent way to save money!
Though cost-sharing reductions can be beneficial, they don’t always cover all your out-of-pocket medical expenses for the year. Therefore, you should also take into account your expected out-of-pocket medical expenses and what budget you have set for yourself.
Selecting the ideal Bronze health plan is a significant decision for many individuals and should not be taken lightly. You need to evaluate whether or not the monthly premiums are worth the lower out-of-pocket expenses and preventive care included with a Bronze plan.
If you don’t need or want comprehensive coverage, but want a health plan with a moderate monthly premium and cost-effective care when needed, the Silver plan is an ideal option. Plus, if you qualify for cost sharing reductions (CSRs), which save money on deductibles, copayments and coinsurance when receiving care, this option becomes even more appealing.
Plans in this metal tier are the most popular choices for Marketplace shoppers. Under ACA regulations, plans at this level must have the same deductible, copayments and coinsurance for most services.
If you require more comprehensive coverage or aren’t eligible for CSRs, gold plans may be suitable. While these plans tend to be costlier than silver and bronze options, they often offer better savings on deductibles, copayments and out-of-pocket expenses when visiting your doctor or hospital.
One of the greatest achievements of the ACA was its requirement that all Marketplace plans include basic healthcare benefits. These essential services include medical and dental coverage, prescription drug coverage, mental health/substance use disorder coverage, preventive care, and maternity coverage.
Benefits may differ by plan, so be sure to carefully compare the plans you’re considering. In general, Silver plans offer coverage for a wide range of medical costs.
Silver plans stand out due to their availability of cost sharing reductions (CSRs). These discounts boost the actuarial value of Silver plans for those whose incomes range from 100% to 250% of the federal poverty line.
Gold plans typically carry higher premiums than Silver and Bronze plans, but they also cover a greater portion of your medical costs. As such, they may be the best option for those who anticipate frequent doctor visits as well as need for regular prescriptions.
Gold plans may be more budget friendly if you qualify for the advanced premium tax credit (APTC). To apply, you’ll need to determine your income and federal poverty level multiplier; most those who do will receive assistance.
In addition to premiums, you’ll pay deductibles, copays and coinsurance when using your plan. These out-of-pocket expenses can add up quickly so it’s essential that you carefully compare all options available to you.
The health insurance marketplace divides all eligible plans into four tiers: platinum, gold, silver and bronze. While these do not affect the quality of care you will receive from your plan, they do influence how it pays for healthcare expenses.
The actuarial value (AV) of your coverage is an estimate of how much money it will save you in the long run. A Gold plan’s AV is 20% higher than that of a Silver plan and 80% greater than that of Bronze coverage.
Platinum plans are an individual market option (they tend to not be offered in small group or individual markets). Although these health coverage options tend to be the most costly options available on the market, they can also provide high-use healthcare consumers with excellent coverage options.
The Affordable Care Act created four metal-level categories for individual and small group health plans: bronze, silver, gold, and platinum. As you move up the tiers, benefits become more extensive as premiums tend to be higher in each tier.
However, it’s essential to be aware that all levels of insurance offer standardized actuarial values; this means they guarantee to cover healthcare expenses based on average costs across a standard population. So even with a platinum plan’s actuarial value, enrollees cannot expect exactly 90% coverage.
This varies based on how often a person uses their healthcare, their risk tolerance, and the cost of services. Nonetheless, platinum plans often boast higher actuarial values than any other plan (for instance, strong cost-sharing subsidies can boost silver plans’ actuarial values up to 94% compared to 90% for platinum plans).
In the end, whether you select a platinum or any other metal-level health plan is an individual decision influenced by several factors. As such, consulting with an experienced health insurance professional before making major changes in your coverage is recommended.