One provision of the ACA is to standardize and improve individual health insurance policies. This was done by creating a “metal” ranking for individual/family and small group policies, based on their actuarial value (the percentage of costs that the plan pays across a standard population; for each individual member, however, the percentage of costs that the plan pays will depend on the costs the person actually incurs during the year).
- A Bronze plan will cover roughly 60% of costs
- A Silver plan will cover roughly 70% of costs
- A Gold plan will cover roughly 80% of costs
- A Platinum plan will cover roughly 90% of costs (Platinum plans are fairly rare in the individual market).
- There’s an allowable de minimis range that allows actuarial values to vary slightly; note that this range has been tightened up as of 2023.
But again, those averages are across an entire standard population of enrollees — for an individual person, the percentage of costs covered by the plan in a given year will depend on how much health care the person needs. A person with significant claims may pay only a tiny fraction of the total costs, whereas a person who only has a few doctor visits in the year may pay all or most of the costs, depending on the plan structure.
The metal designations apply to plans both in and out of the exchanges. Regardless of the metal level, non-grandfathered private plans cannot have out-of-pocket maximums that exceed $9,100 for an individual and $18,200 for a family in 2023.
It’s important to understand that cost-sharing reductions will increase the actuarial value of a Silver plan, in some cases making it better than a Platinum plan. If your income is modest and you’re shopping in the health insurance marketplace/exchange, it’s highly recommended that you carefully consider the available Silver plans. You might find that they provide better coverage than the Gold or even Platinum plans.
