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Ever experienced healthcare insurance overload while scrolling through an endless list of Marketplace plans? We’ve been there. One (super useful, underrated) way to help narrow your choices is to learn the metal tier system the insurance providers use to categorize their offerings.
If you’re looking for some clear guidance in the world beyond employer-sponsored healthcare, join the TRN team as we tour the tiers and break down your options.
The Metal Tier Model of Cost-Splitting
In an effort to streamline the selection process, the Affordable Care Act (ACA) grouped Marketplace plans into four different levels based on cost breakdowns. These four levels, or tiers, were named after precious metals: Platinum, Gold, Silver, and Bronze.
First things first, a disclaimer: the metal tiers are divided and categorized based on how your healthcare costs will be split between you and your insurance provider. Metal tiers are not meant to represent differences in the quality of care you’d receive based on your plan selection.
The 10 Essential Health Benefits
All ACA Marketplace plans—no matter the tier—are required at a minimum to provide what’s known as the 10 Essential Health Benefits:
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and addiction treatment
Prescription drugs
Rehabilitative services
Laboratory services
Preventative, wellness, and chronic disease care
Pediatric services
Touring the Tiers
Now that we know what the metal tiers represent let’s break down the details of each level and what type of consumer they’re intended to serve. Generally speaking, the lower the metal tier, the lower the monthly premium costs. On the other hand, lower metal tiers also come with higher deductibles and out-of-pocket costs when you need to seek care.
The good news is that the Affordable Care Act (ACA) has placed mandatory out-of-pocket spending caps on all Marketplace plans, regardless of the tier. For 2023, the maximum limit for out-of-pocket expenses has been set at $9,100 for an individual and $18,200 for a family. You can also apply for income-based tax credits to help defray your monthly premium at any tier level.
Bronze: The Medical Minimalist
The Pros: Bronze plans cover essential services and offer the lowest monthly premium costs.
The Cons: There’s always a tradeoff. On the flip side, when you do need medical care, Bronze plans come with higher deductibles and out-of-pocket costs than the other tiers.
While a Bronze plan definitely isn’t for everyone and could feel too risky for some, it may be a fit if you don’t often seek medical care or anticipate needing a lot from your healthcare plan.
It’s a basic plan that provides some financial buffering in case of an emergency and allows for a relatively low monthly payment, especially if you qualify for additional tax credits on your monthly premium.
Key takeaway: Look at your plan’s deductible and annual out-of-pocket maximum and make sure you can afford the worst-case scenario costs.
Silver: The Streamlined Shopper
The Pros: You’ll see moderate pricing on the front end (your monthly premium cost) and when you seek medical care (your deductible and out-of-pocket maximum).
The Cons: You get neither the lowest monthly premium payment (Bronze) nor the lowest deductible or out-of-pocket maximums (Gold or Platinum).
Silver plans are popular for the medical middle ground they offer. On the one hand, Silver plans don’t cost as much upfront as the higher tiers, but they do chip in for more services and offer a less risky deductible/out-of-pocket maximum combo than Bronze plans.
Key Takeaway: This plan may be a fit if you maintain a few prescriptions or need a little more than the standard annual checkup but don't anticipate surgeries, chronic disease support, or more involved care. Still, be sure to check the deductible and out-of-pocket maximums to ensure you can afford them in case of emergency.
Gold: The Service Seeker
The Pros: This tier offers a reliable safeguard and a plan that’s likely to pitch in and share costs on most, if not all, of your medical services. With a Gold plan, you’ll see lower deductibles and out-of-pocket maximums than with the Silver or Bronze tiers.
The Cons: As always, it’s a tradeoff. Offsetting the more generous cost-sharing model is the Gold plan’s higher monthly premium.
If you or any family members covered by your plan will need surgery, maternity care, services and support for a chronic medical condition, or the like, a Gold plan may be a good fit.
Key Takeaway: Gold plans offer security and peace of mind in terms of providing care coverage when you need it, but be sure to budget for the higher monthly premiums that come with them. You'll want to ensure your monthly payment is affordable so you don’t risk getting behind or losing coverage entirely.
Platinum: The Peak Protector
The Pros: Platinum plans offer the overall lowest out-of-pocket costs and deductibles when you seek medical care.
The Cons: The monthly premiums on Platinum plans may be impractically high and not necessarily more beneficial than choosing a solid plan in the Gold tier.
Platinum plans, while boasting the lowest costs on the back end, are often impractically expensive in terms of upfront monthly premiums, making them the least popular plan tier.
Key Takeaway: Platinum plans make the most sense for consumers who know they will need extensive medical care at all times and aren’t commonly used. If you’re torn between Gold and Platinum plans, it may help to consult with a licensed health insurance agent who can look at the specific type of care and prescriptions you’ll need and which cost-sharing model may best serve you in the long run.
Take Your Time and Plan Ahead
Take time to decide which tier is right for you and stay on top of open enrollment or special enrollment periods if you need to update your plan due to changes in family size, medical needs, or finances.
Based on your household income, you may also qualify for special tax credits to defray the cost of your monthly premium. If your income changes during a plan year, be sure to update that information in your ACA account.
What’s Next?
Still trying to figure out the right plan for you? Totally normal! Health insurance is one of the most complex topics out there today. Even if you understand the metal tiers and how they apply to your situation, there are many other factors to consider before you finalize your plan.
Luckily, you don’t have to do this alone.
When you work with a licensed health insurance agent who's committed to understanding and educating their clients, you can receive guidance that’s tailored to your situation and needs. And if you need help finding an agent you can trust, that’s our specialty. We’re not health insurance agents; we’re the matchmakers who are passionate about connecting consumers with experts you can trust.
Find out how to secure the coverage you need for your healthiest life.
Want to be a part of the #TRN Team? We are looking for guest writers to contribute to our blog. Reach out to jo@trustedreferral.org to learn more.