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

FAQ

Differences in Metal Levels

• 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.
  • 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.

• How do mental health therapist benefits vary amongst the four metal levels?
  • Unfortunately, almost 1/2 of therapists don’t take any Insurance. Thus, you’ll have to check the out of network provisions in the Summary of Benefits or EOC Evidence of Coverage.
  • See the Metal Level Chart above and note the difference in co-pay between the metal levels under Primary Care and Specialist Visits.
  • HDHP so you can get an HSA Health Savings Account and pay the bills tax preferred!

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

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?
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  • Term Life Insurance
  • Inequity Continues at Covered California with No Deductible Health Plans

§156.140   Metal Levels of coverage.

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