Metal Levels

In the individual Marketplace plans will come with up to 5 levels of coverage.  The categories are given metallic names to designate the level of coverage.   All plans in a particular category must have an actuarial value of 60, 70, 80, or 90%.  What does this mean?  This is the amount of claims, on average, that a plan would expect to pay for a large group of group of people.

ActuarialValues2

In other words a plan with a 60% actuarial value would be expected pay 60% of the claims for a large group of people and the members would pay the rest out of their own pockets.

There is a 5th category called a catastrophic plan.  This is available to only to individuals who are under the age of 30 or who have been certified as exempt from the individual responsibility payment (individual mandate) because they cannot afford minimum essential coverage or because they are eligible for a hardship exemption.

 Q.        Does this does not mean that a silver plan will pay 70% of all of my claims.

A.        No, your results depend on the amount and type of claims you actually have.

Here are some examples of what these metal plans might look like.   Please keep in mind that insurance carriers are free to adjust the benefits (such as deductibles, copays, out of pocket limits) as they see fit as long as the result fits in the proper actuarial value designation.

Sample PlansHere are a few more important things to know.  Under the new rules, all cost sharing counts towards the out of pocket limit in the plan.  This means that if you pick a plan that has doctor or prescription drug copays, they will stop if your cost share reaches the plans out of pocket limits.

Warning:        If you get service from an out of network provider all bets are off on what your share of the cost may be.  Some plans may have NO coverage for out of network services.

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