There are four different tiers of medical plans called metal levels. The four metal tiers are: Bronze, Silver, Gold, Platinum, and these tiers are similar to those in individual health insurance plans.
Here we write about how the four tiers of insurance differ so that you can plan your team's health coverage more effectively.
In health insurance, what does metal level mean?
A metal tier represents the split of cost-sharing risks between a plan's participants and its insurer. By indicating the amount of employee payments and insurance company payments, consumers can compare health plans more easily.
Despite having the lowest premium, Bronze plans have the highest cost-sharing requirements. Premiums for a Platinum insurance plan are the highest, while out-of-pocket expenses are the lowest.
The following costs are typically shared:
Deductibles are payments you must make for covered services before insurance coverage begins.
When participants have met their deductible, a portion of the costs of covered services is paid by the insurance plan through coinsurance.
Payments participants make on top of the coverage payments made by their insurance plans are called copayments.
In the table below, you can see the average insurance cost-sharing for each metal level
In actuality, the employee's out-of-pocket expense depends on how many health care services they require during a given year.
A Silver health insurance plan, for example, would cost less than 30% out of pocket for an employee who only needs an annual checkup. However, if they spend an extended period in the hospital due to an illness, they may have to pay out of pocket more than 30% of their expenses to meet their deductibles.
Out-of-pocket expenditures are also limited for each metal tier. An employee would have to pay this amount in a covered year before their health insurance plan would pay 100% for in-network care.
No matter what metal tier a plan is in, the maximum limit in 2021 is:
$8,550 for individual coverage
$17,100 for family coverage
There generally are higher maximum limits on Bronze insurance plans and lower limits on Platinum plans. In other words, the cost of actually using your medical insurance is generally highest for Bronze plans and lowest for Platinum plans.
Metal levels refer only to the cost-sharing requirements for plans that are in-network. Since January 1, 2014, all small group and individual plans must include at least ten essential health benefits (EHBs), regardless of metal level.
How do I choose a metal level as an employer?
If your goal is to reduce health care costs, price is an important consideration, but you must also think about whether your health plan will cover the potential range of needs of your employees.
As a result of HIPAA (Health Insurance Portability and Accountability Act of 1996), you cannot ask about a worker's health status.
To get more insight into your employees' needs, you should conduct an anonymous employee survey. Among general questions you can ask is whether they prefer high premiums or higher deductibles or whether they are planning to add dependents to their plans.Then based on the results a general guide to selecting a level would be:
Rarely falls ill and does not need many medications
Has good health
Has older children who are healthy and stay away from risky activities if they are enrolled in family coverage
Has one or two mild conditions that require specialist diagnosis and treatment but is not frequently hospitalized (as are their family members).
Has a physical capacity and is under 70 years of age, as well as any covered family members
Have children who are at least elementary school age, are in good health, and do not play sports at risk for serious injury
Experiencing a chronic medical condition or has a family member with a chronic medical condition
Requires expensive medications or visits the doctor frequently
Have children who are preschool age or younger, and see a pediatrician frequently
Are older and/or more at risk for colds or the flu
Is suffering from an expensive chronic disease that requires multiple medications or has someone in the family who is
Has more than one emergency or urgent care encounter per year
More than one visit per month to the doctor and/or frequent medical exams
Has a high risk of cold, flu, or injury if they are older or at a high risk
What's the difference between bronze and silver plans?
Even though Bronze and Silver insurance plans provide similar coverage, they differ in some significant ways, aside from the differences in premiums and out-of-pocket costs.
Bronze insurance plans
Bronze Level Plans
Many Bronze plans are considered high-deductible health plans (HDHPs), and some come with health savings accounts (HSAs) to help employees offset out-of-pocket expenses.
There are, however, some Bronze plans that are not HSA-eligible. Bronze plans must meet the following requirements:
The deductible is higher than that of most individual health plans
There should be a maximum out-of-pocket cost and deductible for each year
You aren't covered until you meet the deductible. The following expenses are covered:
Premiums for health insurance
Preventive care and wellness
Costs associated with dental and vision care
Silver Level Plans
Under the ACA, some Silver plans are used as benchmark plans. Benchmark plans include:
Silver plan with the second-lowest cost within a coverage area; premium subsidy calculation for individual plans is based on this plan. No matter what plan someone chooses, they must know the cost of the benchmark plan premium before calculating their final tax premium credit.
It is the plan that a state uses to define the essential health benefits (EHBs) for individuals and small groups (not always Silver). State-run EHBs are allowed as long as they meet or exceed the federal requirements. However, there are general guidelines set by the federal government. A state can choose to have a benchmark plan that has three on-formulary medications in each therapeutic category despite the ACA's requirement that a plan have at least one within each therapeutic category.
There is a list of benchmark plans through 2021 provided by the Centers for Medicare & Medicaid Services (CMS). In a given state, the benchmark plan must include all essential health benefits, but health plans can also have optional benefits.
Check out your state's benchmark plan or contact us to see how EHBs are defined, and if anything else is required by the state.
It is possible that the benchmark plan is not a metal level plan. You will, however, be able to compare health plans with additional benefits and coverage once you know the requirements for your state's health insurance. You can then determine if the benefits of a particular plan are worth the additional cost.
Which metal tiers are the most popular among small businesses?
Small businesses mostly choose Silver and Gold plans, according to a report from eHealth on health insurance trends for 2018.
Is it possible to choose more than one type of metal plan?
You may have the option of offering more than one health plan to your employees, depending on where you purchase coverage.
You can offer employees multiple affordable health plans through the Small Business Health Options Program (SHOP).
If you want to buy health coverage through SHOP, you must meet the following expectations:
One to fifty people working full-time or equivalently
You should have a main business address in the state where you want to buy insurance
Ensure at least one employee is enrolled in the plan who isn't the employer, his/her spouse, or their business partners
Ensure that all employees have access to the SHOP
Using a SHOP-registered agent or broker such as Benton Oakfield, will also allow you to choose multiple plans. Moreover, some private exchanges for small groups, such as New York State of Health, let you pick more than one metal tier.
It is possible to obtain health insurance outside of the public or private exchanges by speaking with an agent or broker. You can offer your employees multiple tiers of insurance coverage if you meet certain conditions with the insurance carrier.
What is the best way to communicate my choice to my employees?
Your insurance company will provide employees with a copy of their summary of benefits and coverage (SBC) once you select a plan. An outline of the plan's contents and the price is provided in this document.
You must provide employees with copies of each plan if you offer more than one choice.