Find your best tier plan
More than 20 million people now have health coverage through the Affordable Care Act — bringing the number of uninsured to its lowest rate in four decades. But as the fourth open enrollment cycle gets underway, a recent survey by the Kaiser Family Foundation found that there are still 27 million uninsured across the country. The main reason? Cost. “That continues to be the No. 1 reason people name for why they don’t have insurance,” says Karen Pollitz, a senior fellow at the foundation.
Of those who don't have health plans, the majority of which are low-income working families, nearly half — 11.7 million people — would qualify for financial assistance if they signed up for a plan through either Medicaid or a tax credit in an Affordable Care Act marketplace, Pollitz says.
“It’s a two-part process,” she explains. “One is applying for financial help to see if you might be eligible. Then, once you have that determination, the second part is looking for your health plan options and enrolling.”
If your estimated income for 2017 is between 100% to 400% of the federal poverty level for your household size, you qualify for a premium tax credit, which can be put toward offsetting your monthly insurance payment.
And if your income is 250% of the federal poverty level or lower, you could qualify for extra savings in the form of cost sharing reductions.
New York State operates its own marketplace, New York State of Health (nystateofhealth.ny.gov), and residents might qualify for financial aid through one of its Insurance Affordability Programs — Medicaid, Child Health Plus, Advance Premium Tax Credits and Cost-Sharing Reductions. Beneficiaries can determine their eligibility for extra savings during the enrollment process or by using the online Estimated Financial Help calculator. Within the marketplace, plans are offered in four different categories of coverage — bronze, silver, gold and platinum — which are commonly known as the metal tiers. All plans cover the same essential health benefits like hospital stays, prescription drugs, maternity care, mental health and doctor visits. The main difference between them is their cost-sharing split — the amount a beneficiary pays versus how much their insurance company pays for their medical services. In general, a beneficiary in a bronze-tiered plan would pay 40% for their coverage while their insurance company pays 60%; the split is 30/70 for a silver plan, 20/80 for a gold plan, and 10/90 for a platinum plan.
“The bronze plans generally have the lowest premiums, the amount that you pay each month, but the highest deductibles and other cost sharings,” Pollitz says.
“So it’s not unusual to see bronze plans that have a $5,000 or $6,000 deductible, per year per person, before the plan will reimburse anything. So all your doctor visits all year long, all of your ER visits, you might end up paying out of pocket,” Pollitz says.
“The silver plans tend to have somewhat higher premiums but lower deductibles, although still pretty high. In most areas, it's $2,000 to $3,000. With gold plans, the trade-off continues — even higher premiums but lower deductibles.”
Platinum plans, meanwhile, tend to be the most expensive month by month.
“But you will pay the least amount when you go to the doctor or if you need hospital care,” Pollitz adds.
“It’s the cost of that monthly insurance payment that motivates most people’s choices when picking a health plan or metal tier,” says Eric Gascho, vice president of government affairs for the National Health Council,
“What we’ve seen is that most people are purchasing their plans based on the premium and that’s the No. 1 thing driving their decision,” he says.
“However, for people with chronic conditions, it would make a lot of sense for them to look at some of the higher metal levels, the platinums and the golds, because while they will have a higher premium, they will also have lower cost-sharing.
“A lot of the platinum plans have a reduced out-of-pocket maximum. So for someone who is going to be utilizing a lot of services, that could save them a lot of money in the long term.”
Those who are eligible for extra savings should pay special attention to the silver plans, Pollitz advises. “If your income is 250% of the poverty level or less, there are modified silver plans available to you. They’re still called silver; they cost the same as regular silver plans, but they’ve been modified so that the deductibles are more like what you would find under a gold or a platinum level plan. You won’t find those cost sharing subsidies in any other tier.” habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care.
this is the complete list of drugs covered under your marketplace health plan.
What falls under a formulary can vary from plan to plan, so it’s important to compile a full list of the current prescriptions you’re taking to confirm they are covered prior to picking a plan.