Even though the Affordable Care Act (ACA) has been around for a dozen years, not everyone understands how “metal tiers” work. Nor do they know that selecting the least expensive tier does not always mean the lowest cost. Below, we provide some information and tips designed to help you answer your clients’ metal tier questions.
Whether your customers are shopping for individual coverage (through Covered California, Nevada Health Link, HealthCare.gov, or on their own), or they are small business owners shopping through you or on their own for group health coverage, it is important they know about ACA metal tiers.
The four ACA tiers – Bronze, Silver, Gold, and Platinum – are designed to make it easier for those shopping and enrolling to compare and select the right health coverage for their individual or family health care needs. Each tier aligns with the benefits offered by plans in that tier, according to a plan’s actuarial value, which is the percentage of total costs for covered benefits. It also is a good way to forecast cost sharing when visiting a doctor or being treated, in-patient or outpatient, at a hospital in a health plan’s provider network.
Here is an overview of the ACA Metal Tiers in the employer-sponsored market:
| ACA Metal Tier | Portion of Covered Services Paid by the Health Plan (Insurer) for In-Network Services | Portion of Health Care Costs Paid by Insured Patient for In-Network Services |
| Bronze | 60% | 40% |
| Silver | 70% | 30% |
| Gold | 80% | 20% |
| Platinum | 90% | 10% |
ACA’s “De-Minimis” Variations: The law allows states to broaden or reduce the federal ACA standard for actuarial values within metal tiers. While federal ACA law has changed several times over the years, it currently allows states to enhance or reduce a plan’s actuarial value within each metal tier by -4/+2%. For example, this means a Gold plan could have a 76%- 82% actuarial value instead of the standard 80%. Each plan varies.
Which tier is right for your clients? That depends on their specific health care needs, the employer’s contribution to group coverage, and their personal budget.
A Bronze-tier health plan:
-Offers the lowest monthly premium
-Includes higher out-of-pocket costs when care is needed
-Can have a deductible of thousands of dollars annually (this amount must be paid before the health plan begins to pay, with the exception of wellness and some telehealth services)
-Is a good choice if your customer wants a low-cost way to protect them from medical scenarios (such as a serious sickness or injury)
While the monthly premium is lower with a Bronze-tier plan, annual costs for your clients (or their employees) could be higher for those who need a lot of medical care. That’s because applicable deductibles, if any, and the higher co-pay amounts can add up quickly for covered (and uncovered) health care services.
A Silver-tier health plan:
-Offers a modest monthly premium and moderate costs when care is needed
-Has a deductible that is typically lower than a Bronze-tier plan
-Is a good choice if your customers are willing to pay a slightly higher monthly premium and want to have more of their routine care covered
A Gold-tier health plan:
-Generally has a higher monthly premium (than a Bronze- or Silver-tier plan)
-Offers lower costs when care is needed (because the plan pays a greater portion of the costs for covered services and the deductible is typically less than with a Silver or Bronze plan)
-Is a good choice if your customers are willing to pay more each month to have a larger portion of their health care costs covered when seeking care
If your clients expect to need a lot of health care, many health care experts suggest a Gold-tier plan can often be a good value.
A Platinum-tier health plan:
-Has the highest monthly premium (of the four tiers)
-Offers the lowest cost when care is needed (because a Platinum plan pays the highest percentage for covered services when seeking in-network treatment)
-Typically has a lower deductible (the amount your customer must pay before the plan begins to pay for covered services)
-Is a good plan choice if your customer is willing to pay more each month to have a greater percentage of eligible medical services covered when seeking care
ACA-compliant small group and individual health plans in all four metal tiers include 10 Essential Health Benefits, including free preventative/wellness care. Some also offer free or discounted services for eligible care before the patient pays the deductible.
Word & Brown offers a diverse range of health plans from premier health insurers regionally and nationally. Visit our website for a carrier and administrator list by product and state. Or, contact your Word & Brown representative to learn more. If you’re not already doing business with Word & Brown, call (800) 869-6989.
