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New Standards for Benefits and Plan Designs

What are "metal" plans – Bronze, Silver, Gold, and Platinum?

Today, health insurance companies offer many different plans for you to choose from, and the choices can be very different from company to company. In 2014, health insurers will need to offer plans that fit into “tiers” or “levels” called Bronze, Silver, Gold, and Platinum. These metal levels are designed to make it easier for shoppers to compare options. As you might guess from their names, the metal levels increase in benefit value with each level. Platinum plans will offer the most generous benefits, and bronze the least.

Within a single metal level health insurers can offer a variety of plan options. The deductibles, copayments, and even coinsurance levels may vary for those plans. There will also be differences in provider networks, prescription drug formularies, value-added benefits, and customer service. Some plans may even include innovative approaches to help people become more involved in their health and wellness. What the plans within a metal level have in common is that in total, they provide about the same overall coverage for essential health benefits for the average pool of people. The percent of covered benefits will be different for each person, based on what benefits are actually used.

What about catastrophic plans?
With one exception, all plans sold to individuals or small businesses, in or outside of the exchange, must fit into one of the four metal-level categories. The one exception is the “catastrophic plan,” which doesn’t fit a metal level and has coverage below the Bronze level. This plan is only available to people under age 30, or who are exempt from the requirement to purchase coverage because the premium would exceed 9 percent of their income.  The catastrophic plan will only available through the exchange, and no cost-sharing subsidies can be used for it.

Will dental, vision, and chiropractic care be covered?
If chiropractic care, vision, or dental coverage is important to you, you’ll still be able to enroll in that coverage through the exchange marketplace or on the outside market.

  • While acupuncture, and naturopathic care, isn’t a required benefit in the new metal level plans, chiropractic care is considered an essential health benefit. All metal plans will automatically include chiropractic coverage.

  • Vision exams for children under age 19 are considered an essential health benefit (EHB). All the metal level plans will automatically include coverage for pediatric vision exams. For adults, vision isn’t an EHB; you may find some medical plans that include adult vision exams and some that don’t. You’ll also be able to buy a separate vision insurance plan from a health insurance company outside the exchange marketplace. Federal premium assistance can’t be used to pay for adult vision benefits because they’re not considered essential health benefits.

  • Dental exams for children under age 19 are also considered an essential health benefit, but health insurers aren’t required to build that coverage into their medical plans. They have the option of including pediatric dental benefits in the medical plans, or offering it as a separate plan. If your family includes children under age 19 you’ll need to make sure your child’s coverage includes pediatric dental, whether it’s included in the medical plan or added separately. If you qualify for federal premium assistance, it can be used to pay for pediatric dental coverage but not for adult dental coverage. For adults, dental is not considered an essential health benefit.

    Dental plans with coverage for adults will be offered as a stand-alone option both through the exchange marketplace and direct from an insurance company.

 

Required?

Included in medical plan?

Available as a separate plan?

Chiropractic care

No

Yes

No

Adult vision

No

Optional; will vary

Yes, outside the
exchange marketplace

Pediatric vision

Yes

Yes

No

Adult dental

No

No

Yes

Pediatric dental

Yes

Optional; will vary

Yes

Learn More: What is a Summary of Benefits and Coverage?

Oregon Information for
Montanans with individual or family coverage

Table of Contents

Healthcare Reform: The Basics

Exchange Marketplace: A New Shopping Option

New Standards for Benefits and Plan Designs

Financial Assistance for Health Insurance


Not an Montana resident?
Click here.

Questions?
Talk with a Coverage Advisor.
Call (855) 330-2792 or email reform@pacificsource.com.

Are you eligible for subsidized coverage?
Use this subsidy calculator from the Henry J. Kaiser Family Foundation to find out.

Are you a Medicare member?
HealthcareLawGuide.com doesn't address Medicare changes, but you can find information about Medicare and the ACA at Medicare.gov.


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