ACA METAL LEVEL PLANS Flashcards
BRONZE TIER
The Bronze plan covers 60% of approved medical services; policyholder pays 40%. Bronze has the lowest cost premium. Bronze has the highest unsubsidized Annual Deductible. Bronze is not eligible to apply a Cost-sharing reduction. However, Bronze is eligible to apply a Premium Tax Credit.
SILVER TIER
Silver Tier plan covers 70% of approved medical services; policyholder pays 30%. Silver Tier monthly premium cost is considered moderate. Silver Tier unsubsidized Annual Deductible is moderate. Silver Tier is eligible to apply a Cost-Sharing Reduction; and is also eligible to apply a Premium Tax Credit.
The Silver Tier is the most prevalent tier in the marketplace because that’s where the cost-share reduction comes into play based on the income level. The Silver Tier is the most aggressive plan for your client if they qualify for a subsidy.
GOLD TIER
The Gold Tier plan covers 80% of approved medical services; policyholder pays 20%. Gold Tier monthly premium cost is considered high.
Gold Tier unsubsidized Annual Deductible is low. The Gold Tier is not eligible to apply a Cost-Sharing Reduction; but it is eligible to apply a Premium Tax Credit.
PLATINUM TIER
The Platinum Tier plan covers 90% of approved medical services; policyholder pays 10%. Platinum Tier monthly premium cost highest. The Platinum Tier Unsubsidized Deductible is the lowest. The Platinum Tier plan is not eligible to apply a Cost-Sharing Reduction; but is is eligible to apply a Premium Tax Credit.
OVERVIEW OF THE METAL TIER STRUCTURE
Marketplace plans are separated into four metal categories: bronze, silver, gold, platinum. The differences in these pans separate how medical costs are shared between the policy and the policyholder.
CATASTROPHIC PLAN
In addition to the Metal Tier plans, there is an additional option available for clients who are in unique scenarios – catastrophic plans.
In order to qualify for a catastrophic plan, your client must be under 30 years old or qualify for a “hardship” or “affordability” exemption if they’re over 30. Catastrophic plans only cover three primary care visits per year before the plan’s deductible is met.
The monthly premium on these plans is typically low, but clients cannot use premium tax credit to reduce costs. Deductibles are typically very high with these plans. Make sure that if your client qualifies for a tax credit, compare bronze or silver pans with a catastrophic plan to choose the right plan for them. These are often the most economical option for clients looking to maintain a health care budget.
Expanded Bronze
58–65% AV
58–65% AV. A plan may use this option if it either covers and pays for at least one major non-preventive service before the deductible or meets the requirements to be a high-deductible health plan within the meaning of 26 U.S.C. 223(c)(2).
Silver and Gold Plan Availability
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Each issuer, in each medical market it covers – individual or Small Business Health Options Program (SHOP) - must offer at least one Silver and one Gold QHP in each service area where the issuer offers coverage through the Marketplace, and must make its QHPs available for enrollment through the Marketplace for the full plan year for which the plan was certified.
You helped your client, Ahmad, complete the Marketplace application and he’s ready to select a plan. You’ve helped him narrow down his options to two plans, one Gold and one Bronze. Ahmad wants to understand why the Gold plan has a much higher premium than the Bronze plan. Both are health maintenance organization (HMO) plans within the same issuer product. What is the correct response?
The Gold plan has a higher premium, but has lower out-of-pocket costs for essential health benefits than the Bronze plan.
The correct answer is the Gold plan has a higher premium, but has lower out-of-pocket costs for EHB than the Bronze plan. Plan categories are determined by the AV of the plan design. AV is calculated based on the average portion of the cost of providing EHB that is estimated to be paid by the health insurance plan for a standard population. Usually, the higher the AV, the more enrollees pay in monthly premiums and the less they could pay in out-of-pocket costs.
