Home » Brokers » Marketplace Health Plan Guide: Understanding Plan Types & Categories
When looking for a health plan, most flock to the health insurance marketplace for the best plan offerings. Created out of the Affordable Care Act (ACA), the Marketplace offers affordable coverage for comprehensive plans.
Marketplace plans are broken down into four categories known as metal tiers: bronze, silver, gold, and platinum. The biggest difference between each of the tiers are the way costs are split. Essentially, how much will be paid out of pocket by the individual and how much the health plan covers. Regardless of tier, the quality of care does not change. Plans in all the categories provide free preventive care. Some also provide additional free or discounted services before needing to meet your deductible.
Here’s an in-depth guide you can share with your clients to help them as you guide them towards the plan that fits best for them.
Bronze Health Insurance Plans
At the lowest monthly premium, bronze plans are a good option for those who generally see doctors for routine care, such as for annual physicals. While the monthly premium is the lowest, the deductible is usually one of the highest. If you do need care, the out of pocket costs could be thousands of dollars, before the health plan starts to cover any costs.
Bronze plans are ideal for those looking to have coverage at the lowest monthly cost, but are able and willing to pay more for out of pocket costs, should they need to for worst-case scenarios.
Silver Health Insurance Plans
Monthly premiums with silver plans are moderately priced and one of the more popular options. Silver plans are the go-to plan for many. The monthly premium and deductibles generally fall in the middle of all four plan options.
What also makes silver plans the most appealing are the cost-sharing reductions available for those who qualify. Those who qualify for subsidies can save hundreds or even thousands of dollars each year. These reductions are income based and you’ll know if you qualify in real-time when enrolling in a plan.
Silver plans are ideal for those who are able and willing to pay more for monthly premiums. In return, they’ll have more of their medical costs covered due to a lower deductible, reducing out of pocket costs. It’s also the best option for those who qualify for subsidies, further reducing monthly premiums.
Tip: Use a platform with Enhanced Direct Enrollment (EDE) capabilities like W3LL. EDE improves the user experience as there are no redirects when checking for subsidies. Their entire shopping and enrollment experience is one seamless process, on your custom branded platform.
Gold Health Insurance Plans
As the tiers go up, so do the monthly premiums. The benefit of paying the high premium up front is to have lower out of pocket costs. As it relates to the metal tiers, as monthly premiums go up, deductibles go down.
Gold plans have the second highest monthly premium and is worth considering for those who are in need of frequent medical care. There is a possibility of saving more money in the long run for medical costs, but comes with a higher upfront cost.
Platinum Health Insurance Plans
At the highest monthly premium option, you will also have the lowest deductible. Your out of pocket costs for medical care will be much lower when compared to the bronze, silver, and gold plans.
Platinum plans are best for those who typically see doctors on a regular basis and use their health plan coverage often. Though it comes at a higher upfront cost, the long term out of pocket costs are much lower.
Catastrophic Health Insurance Plan
Not a metal tier, but another plan option is catastrophic plans. These plans have a low monthly premium but come with a very high deductible. These plans are meant to be affordable but still provide coverage in case it is needed.
Not everyone can purchase a catastrophic plan. You must qualify by either being under 30 or over 30, with a hardship or affordability exemption. If you qualify, you’ll see that option when shopping for a marketplace plan. Premium tax credits cannot be applied to catastrophic plans.
Cost-Saving Opportunities
Regardless of which metal tier is picked, there is an opportunity to save additional money on monthly premium costs. Premium tax credits are based on household income. When going through the shopping and enrollment process, there is a chance to check for qualified credits. Those credits can then be applied to the final premium before checking out.
Keep in mind, as income changes, so does the premium tax credit. It’s important to have any changes reported as soon as they occur. If not, there is a risk of using more credits than qualified for or missing out on more credits that will lower monthly premiums even more. If more credits are used than what one is eligible for, the money will need to be repaid.
Beyond the Metal Tiers: HMOs, PPOs, and more
The Marketplace has designed a wide range of plans to meet the unique health care needs and budgets of individuals and their households. In addition to understanding the different metal tier categories of individual health plans, learning the different types of health insurance plan types will further ensure the right health plan is selected.
- Exclusive Provider Organization (EPO):These managed care plans cover medical costs when using doctors, specialists, or hospitals in the plan’s network. The only exception are in emergency cases.
- Health Maintenance Organization (HMO): Coverage is provided only for doctors who work for or are contracted with the HMO. Out-of-network costs are not covered, except for in an emergency.
- Point of Service (POS):Expect to pay less for care, as long as you’re using doctors, hospitals, and providers that are in the health plans network. To see a specialist with a POS plan, a referral from a primary care doctor is required.
- Preferred Provider Organization (PPO): If flexibility is needed, PPOs are the way to go. Access is available to providers both in- and out-of-network. It’ll just cost less with an in-network provider and more when using an out-of-network provider, however no referral is needed.
Picking a plan goes beyond monthly premiums. Considering overall costs, deductibles and out of pocket costs, coverage, and much more are enough to confuse anyone. Providing all available options to your clients, and helping them understand what each means is important for both you and them. As an advisor, showcasing your expertise and providing resources will only build trust with your clients.
Looking for even more support? Reach out to our team of experts. We can help guide you and your clients towards resources and a shopping experience that will benefit all involved. The W3LL platform was built for brokers, by brokers and we’re here to serve you.
