Insurance Choices in a Marketplace: FAQ

A health insurance Marketplace, also known as an Exchange, is where you can shop for and compare insurance plans in your state. You can do it online, through an insurance broker, or by phone. Your state's Marketplace has tools to help you compare your choices and pick the plan you need.

In a state Marketplace, health plans are grouped by levels of coverage -- how much they will pay toward the cost of your health care and what services are covered.

Each level is named after a metal:

• Bronze
• Silver
Gold
• Platinum

Bronze plans offer the least coverage, and platinum plans offer the most.

How Do the Bronze, Silver, Gold, and Platinum Levels Differ?

The levels vary by the percentage of costs you have to pay, on average, toward the health care you get.

Here are the percentages of health care costs you pay, on average, for each type of plan:

• Bronze plan: 40%
• Silver plan: 30%
• Gold plan: 20%
• Platinum plan: 10%

You pay your portion of these costs in deductibles, copays, and coinsurance.

In general, the more you pay in monthly premiums, the less you pay out of your own pocket each time you go for a health care service or to pick up a prescription. A premium is what you pay each month to have insurance.

As an example, consider the differences in the bronze and platinum plans.

With a bronze plan:

The amount you pay each time you see your doctor or get a prescription (your "out-of-pocket" cost) is the highest among the different plan levels. But, with a bronze plan, you also generally pay the lowest premium each month, compared with other metal plans.

With a platinum plan:

Compared with the other plan levels, you are likely to pay less each time you see your doctor or get a prescription. But with a platinum plan, you'll also pay the highest monthly premium.

How Does Coverage From a Metal Plan Compare With My Current Insurance?

When choosing a new health plan, you should compare the out-of-pocket costs you pay, the services provided, including prescription drugs, which doctors and hospitals are in your plan, and changes you expect in your health.

If you shop for insurance at your state's Marketplace, you'll see the health plans organized in this way:

• First by metal level: Bronze, silver, gold, or platinum
• Second by price
• Third by type of health plan, such as HMO, PPO, POS, or high-deductible plans with a health savings account

The type of plan can affect how much choice you have in health care professionals, which medications are covered, and your out-of-pocket costs.

I've Heard That All the Health Plans in a Marketplace Have to Cover the Same Essential Benefits. So What's the Difference Between the Plans?

All health plans have to provide certain essential health benefits in order to market themselves on your state's Marketplace as a Qualified Health Plan. These benefits include:

• Doctor visits and other “outpatient care" (which means you aren’t admitted to a hospital)
• Care for children (including vision and dental coverage) and newborn care
• Emergency care
• Hospital care
• Pregnancy, maternity, and newborn care
• Mental health and substance use services
• Occupational therapy and physical therapy
• Certain prescription medicines
• Preventive care, like cancer screenings and vaccines
• Contraception
• Treatment for long-term diseases, like diabetes and asthma

Plans differ by the services they provide. For instance, one plan may cover more or different prescription drugs than another. Only some plans may include bariatric surgery. And not all plans will cover in vitro fertilization. Plans also likely have different doctors and hospitals within their networks. Even within a “metal" tier, some plans may have lower premiums but charge higher cost-sharing for the individual services. There can be variation among the plans on cost-sharing as long as on average they provide the required coverage.

To make sure a plan will cover the care you need, take the time to look at the summary of benefits for any health plan you're considering. If you have a particular doctor or hospital you want to use, make sure they are in the plan’s network.

In a Marketplace, How Many Health Plan Choices Will I Have for Each Level of Coverage -- Bronze Through Platinum?

Your state and the federal governments decide which insurance companies can sell on the Marketplace. All companies they allow must offer at least one silver- level plan and one gold-level one. So your number of choices depends on the state and federal governments and on the insurance companies that choose to sell plans on the Marketplace in your state.

How Can I Get Help Paying for My Insurance?

There are two ways you may be able to get help.

First, there is a tax credit based on two things:

• Your income. In 2209, single people can make up to about $51,040 a year to qualify. A family of four can make up to $104,800 a year to qualify.
• How many people are in your family

A second kind of financial help is called a cost-sharing subsidy. It is determined by using a sliding scale to help lower how much you have to pay each time you get health care. If you qualify, you'll have lower deductibles, copays, and coinsurance.

For this help, in 2021 single people can earn up to $31,900 a year. A family of four can make up to $65,500 a year to qualify. To be eligible for a cost-sharing subsidy, you have to enroll in a silver-level plan.

Will I Get a Larger Tax Credit if I Pick a Platinum Plan?

No. If you buy insurance through a Marketplace, you may qualify for a tax credit that will help lower the cost of your premiums. But you won't get a larger credit for a higher level of coverage. Subsidies are tied to the second-lowest- cost silver plan sold in your market.

How Will I Know if a Plan is Right for Me?

Your state's Marketplace should offer tools and resources to help you choose. For instance:

Ratings for each health plan in all Marketplaces

A cost-calculating tool may also be available so you can see how much your coverage in a specific plan will cost after any premium tax credit and cost- sharing subsidy has been applied.

A toll-free phone hotline should be available so you can call for more help.

Health Care Navigators will be available to help you understand your choices. There will be a link on your state Marketplace to help you find help from one of these organizations.

Read more on: health insurance