The Affordable Care Act (ACA) made it easier for people who don’t get health coverage from an employer to find an affordable plan. In addition to creating online Health Insurance Marketplaces, the law created standard criteria and categories for Marketplace health plans, making comparison shopping among options easier for consumers.
Marketplace plans are categorized by metallic tier1 — bronze, silver, gold, and platinum — based on plan value and cost. How much you pay each month in premiums and as a share of the care you receive, through deductibles2 and coinsurance,3 varies by tier. The higher the tier (gold or platinum), the more you typically pay each month in premiums. In lower tiers (bronze or silver), you may save money on premiums but pay a higher share of medical costs when you use services.
Within each metallic tier are a range of choices, such as HMO or PPO plans,4 that determine where you can get healthcare services and for what cost.
What You Need to Know
Metal tiers indicate how you and the insurer will divide the share of health costs, not the quality of care you get.
All plans sold on the Marketplace cover the same 10 Essential Health Benefits. Some plans offer more, but if it’s sold on the Marketplace, it can’t offer less.
Check the details of the plan’s total costs, including out-of-pocket costs as well as premiums, to make sure the plan fits your needs.
What Are Metal Levels?
The metal levels are used to indicate how much medical cost a health insurer covers. A more “expensive” metal, such as gold or platinum, means the insurer pays a higher share of the cost of a given service or supply. A less expensive metal, such as bronze or silver, means the consumer pays more of the cost.
Keep in mind as you look at plan costs that you may qualify for an ACA subsidy as well.
Defining the Tiers
With bronze plans, you typically pay a low premium each month but higher out-of-pocket fees when you need healthcare services. Bronze plans minimize your monthly costs and are best if you don’t have a lot of health needs.
Silver plans are the most popular. They typically have moderate monthly premiums and out-of-pocket costs.
If you qualify for cost-sharing reductions,5 a form of federal subsidy available to people earning up to 250% of the federal poverty level6 (currently totaling $31,900 for an individual or $65,500 for a family of four) you must pick a silver plan.7 This type of subsidy reduces out-of-pocket costs.
There are other subsidies, called Advanced Premium Tax Credits,8 for people who earn between 100% and 400% of the federal poverty level. These subsidies reduce premium costs. If you qualify for the tax credits, the amount of your subsidy is tied to the second-lowest cost silver plan in your area, called the “benchmark plan.” Though silver plan prices set the subsidy amount, you can choose a plan from any metal tier.
Even with subsidies, you may pay more in premiums for a silver plan than you would in a bronze plan, but you’ll get more coverage.
Gold plans typically have higher monthly premiums, but lower out-of-pocket costs. These plans make sense if you regularly use healthcare services, such as for routine prescriptions or a chronic condition.
You might want a gold plan if you’d rather pay a higher amount upfront to have lower costs for specific services, , rather than unpredictable amounts out-of-pocket.
Platinum plans are how they sound: top of the line. They have the lowest out-of-pocket costs — you only pay 10% of covered expenses once you meet the deductible — but also the highest monthly premiums.
If you have a serious condition and use a lot of services, platinum plans can be a good choice. But because they’re so expensive, only 1%9 of Marketplace enrollees opt for platinum plans.
Check the Details
There are a range of plan choices within each metal level, so you’ll need to check the details of what your plan covers.
Catastrophic plans have low premiums, but very high deductibles (currently over $8,000). You’ll pay out-of-pocket for most of your care until you reach the deductible, after which the plan will cover your eligible expenses. These plans do cover a certain amount of preventive care at no charge, and must cover the 10 essential health benefits.
You can only buy a catastrophic plan if you’re under age 30 or you get a hardship exemption for circumstances such as being homeless, facing eviction or foreclosure, facing significant medical debt, or having filed for bankruptcy.
Splitting the Bill
The table below shows how you and the plan share the cost of care under the various metal tiers:10
|Metal Tier||Insurance Company Pays||Consumer Pays|
Your Costs on a Sample Silver Plan
Consider a sample silver plan with a $450 monthly premium, a $4,500 individual deductible, and 30% coinsurance. You’d pay $5,400 in total annual premiums and $4,500 in out-of-pocket costs until you met your deductible, or $9,900 total for the year.
After you met your deductible, if you needed $1,000 in services, you’d pay $300 in coinsurance, or $3,000 if you needed $10,000 in services.
How Do You Choose a Metal Level?
Choosing the right tier depends largely on two factors — your health and your financial situation.
How to Choose
To pick a plan, you’ll need to balance how much you pay each month versus how much you pay out-of-pocket for services.
How often do you go to the doctor — once a year, or every month? Do you have a chronic condition or known health risks? Do you regularly take prescriptions? Are you in a high-risk category for flu or other illnesses?
If you’re likely to use a lot of services or medications, you may be better off with a higher metal tier plan. You’ll pay more each month, but less when you use care. Because you’ll likely hit your deductible earlier in the year, the plan will start paying toward your costs of care more quickly. If you’re relatively healthy and don’t expect to need a lot of care, you might pay less overall with a silver or bronze plan.
Your Financial Situation
While lower-premium plans may be attractive if you’re on a tight budget, it’s important to look at the total cost of each option including monthly premiums, deductibles, copayments, and coinsurance. If you’re likely to use a lot of healthcare services, a plan that costs more each month may actually turn out to be less expensive overall.
Even if you’re relatively healthy and don’t use healthcare services regularly, you could find yourself with unexpected medical bills if you have an accident or become seriously ill. Think about how much risk you’re willing to take. If you have sizable savings, you may be able to handle the higher deductible on a bronze plan.
You can use the available Marketplace tools to compare options and determine what makes sense for you.
How Much Do Plans Cost by Metal Level?
Premiums and deductibles vary by state, carrier, and metal tier. Again, the lower the premium, the higher the deductible.
Your actual premium will depend on where you live, your age, whether you smoke, whether you’re covering just yourself or family members, and the insurance company providing the plan you choose.
National Average Premiums and Deductibles by Metal Tier, 2020
|Average Monthly Premium11||$331||$442||$501|
|Average Annual Deductible12||$6,506||$4,544||$1,519|
The table below shows the average lowest-cost Marketplace premiums for the U.S. and the five most populous states.
Average Lowest-Cost Monthly Premium by Metal Tier, 202113
When choosing a metal tier, first check if you qualify for premium tax credit or cost-sharing reductions. If so, it will help you figure out what you can afford in premiums or whether you need to choose a silver plan (to get a cost-sharing reduction subsidy).
Next, consider your likely health needs in the year ahead. The more services you’ll need, the closer you should look at higher-tier plans. If you don’t expect to need much care and can afford to pay more out-of-pocket if you do, you might save money in a lower-tier plan.
But costs aren’t the only factors you should consider when choosing a Marketplace plan. Check the plan’s Summary of Benefits and Coverage to learn what the plan offers. You’ll need to know, for instance, whether your doctor participates in the plan and whether your prescriptions are covered. This will help you decide whether a plan fits your needs.