Metal Level Chart

The Four  #Metal Levels, Bronze 60, Silver 70 (Enhanced Silver 73, 87, 94), Gold 80 & Platinum 90 

Metal Levels are based on Expected Claims Payment – that is the  actuarial value (AV)

This is one way Health Care Reform hopes to make shopping and comparing easier.   So, if you get a lower priced plan with less or fewer benefits, co-pays, deductibles you simply pay more when you have a claim.  Don’t worry, there is a stop loss – maximum out of pocket OOP, of say $7k so that you won’t break the bank.  All plans cover the 10 Federal essential benefits and CA mandated benefits.

Source and see a sharper image
2022 Patient Centered Designs  * *

Do you think your medical bills will be higher or lower than average for your age & zip code?

Expected  Payout (AV)  MLR Medical Loss Ratio      Bronze 60%    Enhanced Silver 70% - 94%     Gold 80%     Platinum  90%

Resources & Links

Insure Me Kevin.com How 2020 plans work deductibles, etc.   *  Video *

Covered CA on Metal Levels

Covered CA now allows different metal levels for each member of family – Learn More CA Health Line 8.15.2016 * Insure Me Kevin.com 8.2.2016

Affordable Care Act’s cap on annual out-of-pocket health care spending for individuals, regardless of whether consumers have an individual or family health plan.  Final Market Rules 45 CFR Parts 144, 147, 153, 154, 155, 156 and 158

Bronze – Co Insurance after Deductible?

Insure Me Kevin.com

Covering Costs of High Deductible Plan?

Insure Me Kevin.com

Did you just get a big rate increase on your Silver Plan
with Covered CA
and you make too much $$$ to get subsidies?

 

Californians who do not get financial help and buy individual coverage directly from their health insurance company with FREE agent support will not be charged the CSR (Cost Sharing Reduction – Enhanced Silver) surcharge.

In addition, Covered California consumers with Silver plans who do not receive financial help to pay their premium can also avoid paying the surcharge by switching to a different metal tier or buying near-identical Silver coverage directly from a health insurance company, with Free Agent Support. Covered California has approximately 65,000 unsubsidized consumers enrolled in Silver plans.  Covered CA Press Release 10.11.2017 

What are Covered California standard benefit designs?

Health insurance plans must follow Covered California’s standard benefit designs.  With standardized benefits, consumers can accurately compare health insurance plans, because the benefits are the same for all plans offered in the Covered California marketplace. Additionally,  standardizing benefits ensures that the selected health insurance plans define what the consumers get and limit the consumer’s out-of-pocket costs by type of service.

There is also a Catastrophic level,   (high deductible) that one can qualify for, if they are under 30 or the premium is unaffordable as being more than 8% of income.  Open Congress.org   Blue Cross Blue Shield    Blue Shield Catastrophic plan        Email us for rates.  [email protected] 

AB 639 (Chaptered) would Prohibit any [Insurance] product from being offered other than those with a standardized product design [metal level]  in the family  market.   Sounds like what we have with Medi Gap policies. Get the most recent status at http://leginfo.legislature.ca.gov/

I agree it will stifle innovation, so do you want same o same o or to be able to get a plan that fits your needs.  On the other hand isn’t it just a mathematical calculation to see what the actuarial value and essential benefits  is?    Get a FREE quote for Medical Coverage.   Term Life Insurance

sb639.senate.8.6.2013.analysis

§156.140   Metal Levels of coverage.

Link to an amendment published at 82 FR 18382, Apr. 18, 2017.

(a) General requirement for levels of coverage. AV, calculated as described in §156.135 of this subpart, and within a de minimis variation as defined in paragraph (c) of this section, determines whether a health plan offers a bronze, silver, gold, or platinum level of coverage.

(b) The levels of coverage are:

(1) A bronze health plan is a health plan that has an AV of 60 percent.

(2) A silver health plan is a health plan that has an AV of 70 percent.

(3) A gold health plan is a health plan that has an AV of 80 percent.

(4) A platinum health plan is a health plan that has as an AV of 90 percent.

(c) De minimis variation. The allowable variation in the AV of a health plan that does not result in a material difference in the true dollar value of the health plan is ±2 percentage points, except if a health plan under paragraph (b)(1) of this section (a bronze health plan) either covers and pays for at least one major service, other than preventive services, 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), in which case the allowable variation in AV for such plan is −2 percentage points and +5 percentage points.

New Amendment 4.18.2017

(c) De minimis variation. For plan years beginning on or after January 1, 2018, the allowable variation in the AV of a health plan that does not result in a material difference in the true dollar value of the health plan is −4 percentage points and +2 percentage pointsexcept if a health plan under paragraph (b)(1) of this section (a bronze health plan) either covers and pays for at least one major service, other than preventive services, 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), in which case the allowable variation in AV for such plan is −4 percentage points and +5 percentage points.

[78 FR 12866, Feb. 25, 2013, as amended at 81 FR 94180, Dec. 22, 2016]  ECFR.Gov

Final Rule CMS 9929 F comments & discussion – Page 85

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#Catastrophic Coverage
less than Bronze

 

One can qualify for the  Catastrophic level,  Health Care.gov  (high deductible) if they are under 30 or the premium is unaffordable as being more than 8% of income, or possibly a hardship exemption.    Blue Cross Blue Shield .  See the  Federal Hardship Exemption Form for more information.

Check our Quotit Calculator for rates and benefits.  Very few people bother with Catastrophic – Especially if they qualify for enhanced silver.

Learn more on HealthCare.gov

Exemption Forms

https://www.healthcare.gov/exemption-form-instructions/

  1. Anonymous says:
    When/if you think it appropriate I am ready to file a complaint with the state insurance board.Oscar shouldn’t have such a problem selling a policy to someone with an ECN in hand.
    Reply
    • 1st of all, this website is probably the most authoritative site for Catastrophic Coverage in California. We’ve only had two visitors in the past 30 days. Generally, Catastrophic isn’t any less premium than Bronze and there are no subsidies. Finding any information about these plans, without getting into “bogus” plans is difficult. If you’ve found anything authoritative on catastrophic or minimum coverage plans, please post those links in comments below.That said, I’m not surprised that the Insurance Companies are having difficulty finding a procedure to sell you a plan. What kind of crazy thing is this, the “family glitch?”

       

      All that said, I don’t think that a week for an Insurance Company to research something is all that long. I just sent a follow up email.

      I seriously doubt that the DOI Department of Insurance or Managed Health Care would even know what you’re talking about if you made a complaint.

      Reply
  2. Joe says:
    I checked the Covered California website and I do qualify for more than one “hardship” criteria.I probably would need an “Enhanced Minimum Coverage Plan”.
    Reply
    • Steve Shorr says:
      Please, when referring to other website, provide the exact URL. I don’t see why anyone would want the catastrophic – minimum coverage plan. The rate isn’t much less than Bronze.Please advise what hardship you qualify for and why. We must have facts & proof, before making determinations and recommendations.

      Please get a quote, use the icon in the upper right and then we can better discuss what best fits your needs & wants.

      Reply

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6 comments on “Metal Levels – Platinum, Gold, Bronze – Silver & Enhanced

  1. Copied from Facebook Post

    Rick Sanders
    I had quadruple bypass in 2014 had a covered California bronze plan it cost me 6200.00 I picked my doctor and hospital, Best system in the world by far

  2. I’m paying the highest possible premium with a Platinum Plan, why aren’t they covering everything my doctor prescribes or test I need for cancer?

    • Take a look at the Metal Level Chart above and you’ll see that the differences in Platinum, Bronze, Silver & Gold are in the deductibles & co-pays. The metal levels have nothing to do with the quality of care! https://www.healthcare.gov/glossary/health-plan-categories/ See above about CA Standard Benefits Designs. Pretty much, everything maxes out at $7,800 the OOP Out of Pocket Maximum, see definitions and videos ablove. Thus, if you have a $1,000,000 claim, whether you have Bronze, Silver or Platinum the most you pay is $7,800.

      The Law requires that Insurance Companies pay out 80% on Individual Plans and 85% in claims on group plans, see MLR-Medical Loss Ratio above. Thus, the Insurance Companies, don’t really care if you take Bronze or Platinum, they still keep 20% for their overhead and profits.

      The definition for Medical Necessity and Clinical Bulletins are the same for all 4 metal levels.

      The formularies the list of Rx the Insurance Company will cover, are the same. See the formulary page about getting exceptions if you really need the higher cost Rx. The difference is the co pays and deductibles. At least when one turns 65 and goes on Medicare, Part D has an Rx finder when you can put in your Rx Prescriptions and get a side by side comparison.

      Here’s more information on price of Rx, getting exceptions, etc. from a similar prior question.

      If you feel an Insurance Company isn’t paying what they should, here’s our Appeals & Grievance Page.

      Watch Video

      Check out HSA – Health Savings Accounts – the definition of Medical Necessity isn’t regulated by and Insurance Company having to pay out claims… This way you get a High Deductible Bronze Plan and fund yourself any claims before you meet the deductible.

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