Marketplace Metal Tiers

One of the most confusing aspects of marketplace plans is undoubtedly the metal tiers. There are platinum, gold, silver, and bronze. Now, based on the names alone, platinum is obviously the best, right?

Not exactly.

Let’s dive in to help you understand the differences between these types of plans as well as which types of plans might be right for you.

Additionally, we’ll talk about some of the other things you need to take into consideration.

Cost Sharing

First, let’s talk about the plans themselves. The names of the plans have absolutely nothing to do with the qualify of the plans, but the cost sharing structure.

Cost sharing can be broken down into two ways:

• Copays
• Coinsurance

Copays are a fixed amount for a given service or benefit. For example, a visit to your PCP might be $25, Urgent Care $50, and ER $250. These will often be printed on your actual health insurance card.

Coinsurance is a variable amount. So, it is a percentage of the actual cost of the service (often after you have met your deductible).

The metal tiers really indicate the coinsurance sharing structure.

• Platinum: 90/10
• Gold: 80/20
• Silver: 70/30
• Bronze: 60/40

The insurance carrier will pay for the larger percentage of the cost share.

So which plan should you choose?

Monthly Premiums

First, let’s talk about monthly premiums. Very often plans with lower monthly premiums tend to have higher deductibles or cost sharing structures. In terms of marketplace plans, this means that very often the plans with the least expensive monthly premiums will be bronze or silver.

The inverse is also true. Usually plans with higher monthly premiums tend to have lower deductibles and cost sharing structure. So you will often find that platinum and gold plans will have higher premiums.

And remember, with marketplace plans there are many services covered even prior to meeting the deductible and often with no coinsurance/copay. Usually, these are basic or preventative services such as wellness visits or vaccinations.

In general, if you are a basically healthy person, who would like to have a plan in place to take care of basic services and protect you should you need major (and unexpected) medical care, then a lower tier plan such as bronze or silver with lower monthly premiums may serve you well.

On the flip side, if you need more regular medical care or perhaps know you have an upcoming expensive procedure, then a higher tier plan with higher premiums might save you money due to the lower cost share.

We also need to take into consideration premium tax credit eligibility.

For example, based on your premium tax credit eligibility, you may be eligible for extra savings with a silver plan. If this is the case, the cost sharing structure may actually be more advantageous than a platinum plan!

Networks & Benefits

Additionally, there are benefits and networks to take into consideration. All plans must offer at least the 10 essential benefits:

But many plans may offer additional benefits. That being said, these are extra benefits and while you can take them into consideration when making your final decision, they should not be the deciding factor. The other, more basic benefits are far more important. 

And perhaps the hardest thing to qualify are networks. With marketplace plans, you will usually be able to choose between HMOs and EPOs. Sometimes there are PPOs as well. 

With HMOs or EPOs you will only have in network coverage except in the case of a true medical emergency. So you must make sure that the doctors and health systems that you need to use are in the network. 

You can often check with healthcare.gov to determine if your doctors are in network but make sure to speak with the office as well in case they have any planned changes. Your broker should also be able to guide you regarding your plan’s acceptance at large health systems and hospitals.