Metal levels under Obamacare

Gold bars for story on health insurance metal levelsHealth insurance plans sold under the Affordable Care Act come in “metal levels,” with the cost of premiums rising along with the hypothetical metal associated with coverage.

The less-expensive coverage comes under the “bronze” level, and the most expensive comes under the “platinum” tag. In between are silver and gold.

The plans also have percentages attached. Bronze plans, with the lowest premium, pay only 60% of covered health expenses. Platinum plans, with the highest premium, pay 90% of covered health care expenses.

For silver, the percentage is 70 percent and for gold it’s 80 percent.

So the plans are named:

  • Bronze 60
  • Silver 70
  • Gold 80
  • Platinum 90

Of course, the level you select can have a dramatic effect on out-of-pocket expenses beyond the premiums paid each month.

(Note: These examples from California do not take subsidies into consideration, if any. These reduce premiums and/or copayments for those who qualify.)

For example, a 60-year-old in Los Angeles (region 2) would pay $60 for a primary care visit (the copay) under the “Bronze 60” plan, while the copay under “Platinum 90” would be $20. (text continues)

Learn more about applying for Obamacare in California.

That same 60-year-old would pay $120 for an urgent care visit copay under bronze, but only $40 under platinum. For generic medicine, the copay is $19 (bronze) and $5 (platinum).

The big hit comes in the deductible, which is $5,000 under bronze and nothing ($0) under platinum (and gold).

The monthly premium for our 60-year-old would be $518 (bronze) vs. $569 (platinum). The estimate given by Covered California gave our senior a quote of $556 for both silver and gold, most likely an error.

One other clear advantage of ponying up for platinum comes in the “maximum out of pocket” figure. For the first three metal levels, the max is $6,360, while at platinum the max is $2,350 less ($4,000). One major advance for consumers under the Affordable Care Act was the elimination of the lifetime maximum clause, which allowed insurers to walk away from seriously ill customers.

The choice of an HMO or PPO for coverage comes into play at the gold and platinum levels, with HMO members paying a set amount of hospital care costs and PPO members paying a percentage (20 percent for gold; 10 percent for silver).

The HMO charge for outpatient surgery is $600 for gold purchasers, but only $250 for for platinum, suggesting that anyone expecting surgery should give serious consideration to the highest level coverage.

If our 60-year-old had a pre-existing condition and was without employer insurance, the Covered California savings over 2013 market rates for individual insurance (say, Cobra) would be at least 50 percent regardless of metal level.

To get an estimate based on your age and location, use the Covered California cost calculator.

Covered California also offers catastrophic coverage — aka a “minimum coverage plan” — at a greatly reduced rate but with sky-high co-pays. Basically, it’s insurance against bankruptcy or other financial ruin in the event of a serious and expensive medical emergency.

Minimum coverage is available to those up to age 30, or those individuals who prove they are without affordable coverage options or are experiencing financial hardship.