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

are based on Expected Claims Payment – actuarial value (AV).   This is one way (Scroll down to Standard Benefit Designs) 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 essential benefits.

2020 Metal Level Chart

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%    Click here for Enhanced Silver 70% – 94%     Gold 80%     Platinum  90%

What are the four metal levels?
Understanding Health Care Costs
How to find plan that fits budget
Our video on what plan to take if you know you will have a BIG surgery or expense coming up

 

 View our webpage on OOP Maximum Out of Pocket

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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

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including the calculation of the  Cost Sharing Reductions in the Enhanced Silver 73-94% and subsidies – advance premium tax credit, if you qualify based on your income & Federal Poverty Level (Chart).

When you appoint us as Covered CA agent we can assist, advise and research for you, at NO ADDITIONAL charge.  Here’s the instructions.

Resources & Links

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

Covered CA on Metal Levels

2017 Plan Booklet – Metal Tiers

One chart for Metal Levels and Enhanced Silver Cost Share Reductions

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

♦  Detail on Molina Website

Compare Hospitals Outcomes (California Choice – Web MD Tool)

CMS said it will enforce the 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.  the rule capped maximum out-of-pocket costs at $6,850 for individual plans and $13,700 for family plans annually.  Learn More⇒  Our Rx Page  ♦ Modern Health Care 9.15.2015 ♦  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

More detail on Metal Tiers (Covered CA Agent Training)

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Video on Life Changes

 

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

  1. 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
      caps oop

      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.

  2. I have a big surgery coming up. Since it’s Open Enrollment and there are no health questions under ACA/Obamacare, what plan should I get?

  3. I heard some comment on the news about healthcare… The guy said something about Obamacare and how you’re responsible for 7500.00 deductible and how that’s not good…

    • The news reporter is talking about Bronze plan, see above chart for details.

      Subsidies, deductibles and co pays are mainly based on Siver and Enhanced Silver see above.

      With all the court cases going on, the silver rates were increased as the government doesn’t have to pay the enhanced silver extra cost, thus Bronze plan for many of those earning less than say $30k for a single might be $1 or still very little.

      See icon above – three easy steps and get a quote and subsidy calculation.

      Please note also that there is no free lunch. Insurance rates are a function of what the insurance companies pay in your medical bills. See also medical loss ratio and why premiums are increasing.

      Check out this article in the San Luis Obispo Tribune 1.25.2019 on lack of choice and the special low rates going to those who earn between say $17 to 25k for a single, not those who make a 1/2 decent living.

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