The Marketplace Olympics

 Choosing a plan on the Marketplace is like the Olympics. After completing the Herculean task of actually selecting the best plan, you get rewarded with a medal. Or in this case, metal. Bronze. Silver. Gold. Plus an additional metal, platinum! All plans offered on the Marketplace must meet the Essential Health Benefits (EHB) standards created by the ACA.

The metal level refers to the amount of health care costs covered by the plan, called the actuarial value (AV).The ACA specifies that plans offered on the Marketplace must be at one of four levels of actuarial value: 60% (bronze), 70% (silver), 80% (gold), 90% (platinum). For example, a silver plan has an actuarial value of 70%, which means that the plan will pay 70% of the of the health care expenses, while enrollees will pay the remaining 30% through a combination of deductibles, copays, and coinsurance. The ACA also requires that plans have a cap on out-of-pocket expenses for enrollees. The current limits are $7,350 for an individual plan and $14,700 for a family plan. These out-of-pocket maximums are adjusted annually based on premium increases. Bronze plans typically have lower monthly premiums and higher out-of-pocket costs when an enrollee seeks care. In contrast, platinum plans typically have the highest monthly premiums and lowest out-of-pocket costs.

Now that we know how and why the price differs between the four metal levels, let’s look at what benefits are covered. Only plans that meet certain qualifications are eligible to be sold on the Marketplace. To be a Qualified Health Plan (QHP), it must cover the EHB package at the silver and gold AV, at a minimum. QHP’s can also offer benefits outside the EHB but with two limitations: (1) if it covers abortion services, separate premium checks must be collected for that service and premium tax credits or other federal funding cannot be used for those services; and (2) if plans are required by state law to cover services beyond the EHB, states will pay those additional costs.

HHS regulations (45 CFR 156.100) define EHB based on state-specific benchmark plan. States must choose a benchmark plan from among these ten plans in the state: the three largest small group plans, the three largest state employee health plans, the three largest federal employee health plan options, or the largest HMO offered in the state’s commercial marketplace.

Section 1302 of the ACA provides for the EHB package, which includes ten general categories of health treatments, items, and services: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. In addition to the EHB package, the ACA also required coverage for preventive and wellness benefits that are not subject to copays, coinsurance, or deductible payments.

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