Obamacare metal plans

The Affordable Care Act set out to standardize small-group and individual health insurance policies by creating a “metal” ranking for policies, with each level based on actuarial value.

All new small group and individual market health insurance plans — including plans sold in the exchange as well as plans sold outside the exchange — must fall into one of the metal levels (unless it’s a catastrophic plan in the individual market).

With a Bronze plan, the plan members pay roughly 40% of costs. That drops to 30% on a Silver plan, 20% on a Gold plan, and 10% on a Platinum plan.

But these percentages apply to an entire standard population — they aren’t applicable to specific individuals who have coverage under the plan. People with very low overall healthcare spending will typically pay a larger share of their own costs (since they won’t have met the plan’s deductible yet), while a person with exorbitant health care costs during the year might pay only a tiny fraction of the total costs and the health plan will pay the vast majority of the total.

And a person who is healthy enough to only need preventive care during the year might end up with 100% of her health care costs covered by the plan, regardless of what metal level she has, since specific preventive care is covered with no out-of-pocket costs regardless of the metal level.

So across a standard population, bronze plans pay an average of 60% of costs, silver plans pay an average of 70%, gold plans pay an average of 80%, and platinum plans pay an average of 90% (these percentages are referred to as actuarial value).

But it would be too challenging to hit those targets exactly, so insurers are allowed to use a de minimus range instead. Through 2017, it was +/-2 percentage points, which meant that bronze plans had actuarial value in the range of 58-62%, silver plans in the range of 68-72%, and so on.

From 2018 through 2022, the allowable actuarial value range for each metal level expanded, under rules laid out in the 2018 Benefit and Payment Parameters and the market stabilization rule that was published in April 2017. As a result, the de minimus range was mostly +2/-4, with an exception for Expanded Bronze plans, which can have actuarial value as high as 65%. 

But as of 2023, the de minimus range has been reduced, imposing the following actuarial value ranges for metal-level plans:

• Bronze: 58-62% (Expanded Bronze can be as high as 65%)
• Silver: 70-72% (in the small group market, Silver plans can have an actuarial value between 68% and 72%; for cost-sharing reduction variants of Silver plans, the de minimus range is only +1/0)
• Gold: 78-82%
• Platinum: 88-92%

Regardless of the metal level, no ACA-compliant plans can have out-of-pocket maximums that exceed $9,100 for an individual or $18,200 for a family in 2023.

All ACA-compliant individual and small group plans (sold in the exchange or outside the exchange) must fall into one of the metal level ranges, with the exception of catastrophic plans, which are only available to some enrollees in the individual market, and which must have an actuarial value of less than 60%.

Both on-exchange and off-exchange, metal-level plans are available for purchase during the annual open enrollment period for the individual market, which runs from November 1 to January 15 in most states. In the small group market, employers can set their own open enrollment windows for their employees, although employers can purchase a plan for their business at any point during the year.