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Individual & Family Insurance

Individual & Family Insurance 2014-05-07T14:32:39+00:00
On March 23, 2010, President Obama signed the Affordable Care Act. The law puts in place comprehensive health insurance reforms that will roll out over four years and beyond.
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What is Obamacare?

“Obamacare” is a popular name for the Patient Protection and Affordable Care Act since this health reform law was championed by President Barack Obama. While the legislation contained numerous changes to the American health insurance market, its principal aspirations were the reduction of the uninsured population and the lowering of health insurance premiums. The law also contained a tax penalty on Americans who fail to get creditable insurance as well as requirements regarding the types of medical benefits that must be included in health insurance purchased by individuals and small groups. The law also contained a prohibition on insurance application rejections based on health status or pre-existing conditions and premium subsidies for those whose income qualified and whose premiums exceeded a set percentage of income.
Obamacare created new designs for health plans. These new health plans are sometimes referred to as “metal plans” since they are each named after a different type of metal (Bronze, Silver, Gold, and Platinum).

Metal Plans

The four new metal plans are distinguished from one another by their “actuarial value.” Actuarial value refers to the average amount of insurance expenses that would be paid for by the plan. The higher the actuarial value of a plan, the lower the out-of-pocket costs for the plan member. With respect to the plan names, the more expensive the metal, the higher the actuarial value. For example, a Platinum Plan covers 90% of covered medical expenses while a Bronze Plan only covers 60%.
In the market place, it is expected that an insurer will charge progressively higher premiums among the plans with Bronze Plans having the lowest premiums and Platinum having the highest premiums. However, this considers plans only within a single insurance company. It is possible that one company’s Silver Plan could be cheaper than another company’s Bronze Plan. All plans, whether Bronze, Silver, Gold or Platinum, will have a shared maximum out-of-pocket amount that an enrolled individual can pay in a calendar year.
All the plans must offer essential health benefits. These are the basic insurance benefits that all qualified health plans must provide enrollees. States have the discretion to require additional benefits beyond the Essential Health Benefits. However, these are minimum benefits and plans can choose to offer additional benefits so long as the essential benefits are properly covered. It is also important to note that since plans differ by the amount of costs they cover, the aforementioned plans may all cover the essential health benefits but they can cost the member different amounts due to the differences in insurance expenses paid for by the plans. Below is a brief summary of the 10 Essential Health Benefits that all metal plans must offer:

  • Ambulatory patient services (such as doctor visits and other care you receive as a “walk-in” as opposed to services a person receives as an “inpatient” at a hospital or other care facility)
  • Emergency services – These include care received in an Emergency Room
  • Hospitalization – These include medically-necessary surgeries and other inpatient procedures
  • Maternity care and newborn care
  • Mental health services & substance use disorder services – These services include counseling as well as behavioral health treatment for alcohol abuse and drug abuse
  • Drug coverage – This applies to prescription medication and not over-the-counter drugs
  • Rehabilitative and habilitative services and devices – Rehabilitation covers services such as relearning to speak after an aneurysm while habilitative services involve learning a new skill such as managing diabetes through various behaviors
  • Laboratory tests and services (for example, X-Rays)
  • Preventive and wellness services as well as the management of chronic diseases
  • Pediatric medical services (including both oral care and vision care)

Individual insurance companies are not required to offer plans from all four metal tiers. At a minimum, they must offer the Silver plan and the Gold plan. There is also a catastrophic plan for individuals who can demonstrate problems affording a Bronze Plan. This plan is only available through an exchange and tax subsidies cannot be used to reduce its premiums.
Some people have questioned why the metal health plans have the names that they do. Part of the reason is that the Affordable Care Act was based on an earlier health insurance reform in Massachusetts. The Massachusetts plans had the names Bronze, Silver, and Gold. Originally the marketing officer in charge of naming the plans was considering names with historical significance for Massachusetts such as “The Minute Man Plan” and the “Patriot Plan.” However, after hearing the ideas his wife suggested that he use the name of the medals in the Olympics: Bronze, Silver, and Gold. She said that consumers would know instantly that a Silver Plan was better than a Bronze Plan and a Gold Plan was better than a Silver Plan.

How much do metal plans cost?

The monthly premium for any of the four metal plans are based on several factors:

  • Your age
  • Your smoking status (some regions do not allow smoking status to be considered)
  • Where you live
  • The number of people enrolling with you (e.g. a spouse or child)

An additional consideration is the company providing the insurance. For example, the monthly premium for a Bronze Plan for a 30 year-old nonsmoking female in New Haven Connecticut will not necessarily be the same at two different insurance companies serving that region. It is always best to compare plan premiums and benefits prior to enrolling. Premiums for metal plans can be compared on our health insurance premium quote page.

Do I have to buy a metal plan?

As of the time of this article’s most recent update, most individuals will face a fine in 2014 if they do not have health insurance. The fine amount will increase annually until 2016 when it will be adjusted of the cost-of-living. This insurance can be provided by an employer, purchased privately, or be a public health plan like Medicare or Medicaid.

Where do I buy a metal plan?

An insurance company, a health insurance exchange, or an insurance broker can sell insurance. Health Plan Market’s has partnered with various organizations that offer insurance plans.

Can a metal plan’s list of covered medications (i.e. a formulary) change outside the annual enrollment period?

Yes. Insurers are permitted to change their formularies throughout the year as long as those formulary modifications remain compliant with Essential Health Benefit requirements. Moreover, Affordable Care Act regulations require every formulary to include (at a minimum) the greater of one drug in every USP drug category and class or the same number of prescription drugs in each category and class as covered by the benchmark plan chosen by a state. Insurers are not required to submit updated drug lists to HHS throughout the year but may be required to do so for states where the federal health insurance exchange is not used.

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