The Affordable Care Act (ACA) ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits. Essential health benefits must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace.
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 marketplace.
It's 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 metal plans offered by 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 maximum out-of-pocket amount that an enrolled individual can pay in a calendar year before their plan covers the rest of their out-of-pocket expenses.
The premium rates for health insurance plans depend on many factors including coverage benefits and provider network type. Affordable Care Act plans are classified into four metal levels depending on the percentage of costs that they typically pay for covered healthcare services. Obamacare plans also have four provider network types:
PPOs and POS plans cover out-of-network care, while HMOs and EPOs do not. EPO and PPO plans do not require referrals from primary care doctors to see specialists, but HMO and POS plans require referrals for some states.
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