Understanding the Different Metal Plans in the ACA Marketplace
The metal plans in the ACA marketplace are required to provide coverage for the same essential health benefits but differ largely by healthcare costs, including monthly premiums, deductibles, and out-of-pocket expenses.
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- The Affordable Care Act (ACA) marketplace allows individuals to purchase health plans through the federal insurance marketplace or state-based marketplaces, depending on the state.
HealthCare.gov offers four categories of health plans that differ by cost. Regardless of the metal level, all marketplace plans are required to provide coverage for ten essential health benefits:
- ambulatory patient services
- emergency services
- hospitalization
- pregnancy, maternity, and newborn care
- mental health and substance use disorder services
- prescription drugs
- rehabilitative and habilitative services and devices
- laboratory services
- preventive and wellness services and chronic disease management
- pediatric services, including oral and vision care
Plans purchased through HealthCare.gov are also required to cover birth control and breastfeeding services.
The metal tiers do not indicate quality; rather, they differentiate health plans based on monthly premium amounts, out-of-pocket spending, and deductibles. When selecting a marketplace plan, consumers should consider the coverage they need, how often they utilize healthcare services, and the money they can spend on coverage.
Bronze
Bronze plans are considered the most cost-efficient health plans. This option is best for people who typically only go to the doctor for annual physicals, are willing to pay more out-of-pocket for care, or want a low-cost plan that protects them from serious, high-cost medical scenarios.
Bronze plans offer the lowest monthly premiums, but members will be subject to higher out-of-pocket costs if they need additional healthcare. Under a bronze plan, the insurance company pays 60 percent of healthcare costs while members pay 40 percent.
Health insurance deductibles in these plans are also high, meaning people may have to pay thousands of dollars for service before their health plan contributes.
Insurance companies sometimes offer Expanded Bronze plans, which pay slightly more for healthcare services than a standard bronze plan but not as much as a Silver plan.
Silver
Monthly premiums in silver plans are higher than in bronze plans but lower than in the other two tiers. Out-of-pocket expenses will fall in the middle of the four metal tiers, but silver plan deductibles are lower than bronze plans.
In silver plans, the insurance company pays for 70 percent of costs and members pay for 30 percent.
After providing household and income information on a marketplace application, consumers will learn if they qualify for premium tax credits and cost-sharing reductions. Premium tax credits can be used in any plan category, but people who qualify for cost-sharing reductions must enroll in a silver plan to receive these “extra savings.”
Cost-sharing reductions help lower deductibles, copayments, and coinsurance amounts. Consumers who qualify for cost-sharing reductions also have a lower out-of-pocket maximum. When the maximum is reached, the insurance plan will cover 100 percent of all covered services.
If someone enrolls in a silver plan and loses their cost-sharing reductions, they can qualify for a special enrollment period and enroll in a different plan that fits their financial situation.
Silver plans are a good option for those who qualify for cost-sharing reductions or those willing to pay a higher monthly premium than in bronze plans to receive more coverage for routine care.
Gold
Gold plans have the second-highest premium of all four plans. However, these plans have lower out-of-pocket costs and deductibles, making them valuable for people who use healthcare services frequently.
On the other hand, gold plans will likely be more expensive for those who rarely go to the doctor.
The insurance company pays for 80 percent of covered healthcare costs in these plans, while members are responsible for 20 percent.
Platinum
Platinum plans only represent a small fraction of marketplace plans. They have the highest monthly premiums of all plan categories and are best for those who receive regular medical care. These plans can be valuable for people who require a lot of healthcare and are willing to pay high premiums in exchange for other healthcare costs being covered.
Platinum plans offer the lowest deductible and low out-of-pocket expenses compared to other plans.
The insurance company will cover 90 percent of healthcare costs in platinum plans, while the member is responsible for 10 percent.
Catastrophic health plans
Aside from the metal level options on HealthCare.gov, individuals may purchase a catastrophic health plan if they meet certain qualifications. This option may be best for eligible people who want to protect against worst-case medical scenarios, such as getting seriously sick or injured, but will pay most routine medical expenses themselves.
Catastrophic plans cover the essential health benefits required by the ACA but have significantly high deductibles. The deductibles equal the ACA’s annual limit on out-of-pocket expenses, which was $8,700 in 2022 and $9,100 in 2023 for single individuals.
These plans cover up to three primary care visits per year before the deductible is met and cover certain preventive care services with no cost-sharing.
Monthly premiums are typically low in catastrophic plans, but unlike in metal-level plans, members cannot use premium subsidies toward the costs.
In order to be eligible for a catastrophic health plan, individuals must be under 30 years old or qualify for a hardship or affordability exemption. An exemption usually means someone cannot afford health insurance because of certain circumstances.
Common hardship qualifications include homelessness, bankruptcy, domestic violence, eviction, and home foreclosure. Affordability exemptions occur when a person’s income is not enough to be able to afford regular healthcare coverage.
