Comparing health plans
Choosing a health plan can be complicated. There are a lot of things to take into account.
Important. Marketplace Open Enrollment ended March 31. You can still buy a Marketplace health plan only if you qualify for a special enrollment period. You can apply for Medicaid and CHIP any time. Learn about special enrollment periods and other coverage options after Open Enrollment. Open Enrollment for 2015 coverage starts November 15, 2014.
Use this guide to help you understand how to compare plans and choose one that’s right for you.
There are several important things to consider when you compare Marketplace plans.
Plan category: There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic. Plans in these categories differ based on how you and the plan share the costs of your care. The categories have nothing to do with the amount or quality of care you get.
Monthly premiums: This is the amount you pay your insurance company for your plan, usually monthly, whether you use medical services or not.
Type of insurance plan and provider network: Some types of plans allow you to see almost any doctor or health care facility. Others limit your choices to a network of doctors and facilities, or require you to pay more if you use providers outside the network.
Benefits: All plans sold through the Marketplace provide the same essential health benefits and cover pre-existing conditions and offer free preventive services. But some plans offer additional benefits.
Marketplace insurance categories
The health plan category you choose determines how you and your plan share the costs of care. These categories have nothing to do with the quality or amount of care you get.
There are 5 categories or “metal levels” of coverage in the Marketplace. Plans in each category pay different amounts of the total costs of an average person’s care. This takes into account the plans’ monthly premiums, deductibles, copayments, coinsurance, and out-of-pocket maximums. The actual percentage you’ll pay in total or per service will depend on the services you use during the year.
- Bronze: Your health plan pays 60% on average. You pay about 40%.
- Silver: Your health plan pays 70% on average. You pay about 30%.
- Gold: Your health plan pays 80% on average. You pay about 20%.
- Platinum: Your health plan pays 90% on average. You pay about 10%.
- Catastrophic: Catastrophic coverage plans pay less than 60% of the total average cost of care on average. They’re available only to people who are under 30 years old or have a hardship exemption.
What to consider when choosing a plan category
Think about your health care needs when choosing a category of Marketplace plan.
If you expect a lot of doctor visits or need regular prescriptions: You may want a Gold plan or Platinum plan. These plans generally have higher monthly premiums but pay more of your costs when you need care.
If you don’t expect to use regular medical services and don’t take regular prescriptions: You may want a Silver, Bronze, or Catastrophic plan. These plans cost you less per month, but pay less of your costs when you need care.
If you qualify to save on out-of-pocket costs: Silver plans may offer the best value. You may qualify for lower out-of-pocket costs based on your household size and income. If you do, you can get these out-of-pocket savings only if you enroll a Silver plan. If you make this choice you'll basically get the lower out-of-pocket costs of a Gold or Platinum plan while paying a Silver plan premium.
If you’re under 30 or have a hardship exemption and want low monthly premiums: You may want to choose a catastrophic plan designed to protect you from worst-case scenarios, like serious accidents or diseases.
Of course, it’s impossible to predict all your health care needs for the year ahead. Pick a plan that fits your budget and meets your and your family’s expected needs.
Monthly premiums are important, but they’re not all you need to think about. Picking a plan only because its premium is low may not be the best decision for you.
If your plan has a lower monthly premium, your out-of-pocket costs may be higher when you need care.
If your plan has a higher premium, your out-of-pocket costs may be lower when you need care.
Generally speaking, the lower your monthly premium the higher your out-of-pocket costs will be. It’s important to keep this in mind when you compare plans.
If you make $11,490 to $45,960 for individuals or $23,550 to $94,200 for a family of 4, you may qualify for premium tax credits that can lower your monthly premiums. The lower your income is within these ranges, the bigger your tax credit and the more you save.
Preview plans and prices in your area and see if you qualify for lower monthly premiums.
The category of plan you choose affects how much you spend on out-of-pocket costs. Generally, Bronze and Silver plans have lower monthly premiums, but you’ll pay higher out-of-pocket costs when you need care. Gold and Platinum plans generally have higher premiums but lower out-of-pocket costs.
The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan. This means when the amount you’ve paid in deductibles, copayments, and coinsurance reaches these limits, the insurance company pays 100% of your costs for covered care. Even if you choose a catastrophic coverage plan your out-of-pocket costs shouldn’t exceed this limit.
Savings on out-of-pocket costs with a Silver plan
If you qualify for lower out-of-pocket costs based on your household size and income and choose a Silver plan, you can save more. This called a “cost-saving reduction.”
With a cost-sharing reduction, you’ll pay lower deductibles, copayments, and coinsurance. You'll basically get the lower out-of-pocket costs of a Gold or Platinum plan while paying a Silver plan premium. You can choose any category of plan, but you get these savings on out-of-pocket costs only if you enroll in a Silver plan.
If you make $11,490 to $28,725 for individuals or $23,550 to $58,875 for a family of 4, you may be eligible for a cost-sharing reduction. The lower your income within these ranges, the more you’ll save on out-of-pocket costs.
Preview plans and prices in your area and see if you qualify for lower out-of-pocket costs with a Silver plan.
Type of plan and provider network
Different plan types provide different levels of coverage for care you get inside and outside of the plan’s network of doctors, hospitals, pharmacies, and other medical service providers. There are other differences between plan types too.
When comparing your options in the Marketplace, you’ll see health plan details. Make sure to note the type of each plan you’re considering.
To get details about the plan you can also view a summary of benefits, a plan brochure, a provider directory, and a list of covered drugs. If staying with your current doctors is important to you, check to see if they're included in the provider directory before choosing a plan.
You can find quality information about doctors, hospitals, and other care providers by using our quality compare tools.
Preview plans and prices in your area and compare plans by health plan provider.
All Marketplace insurance plans cover the same set of 10 essential health benefits. These include doctor visits, hospitalization, mental health services, prescription drugs, and more. This is true for all 5 plan categories.
All Marketplace plans must also cover treatment for pre-existing conditions.
All plans must cover some screenings, immunizations, and other preventive services before you’ve met your deductible. Many health insurance plans cover other benefits like doctor visits and prescription drugs before you’ve met your deductible.
Essential health benefits are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. You’ll see exactly what each plan offers when you compare them side-by-side in the Marketplace.
Use the links below to learn about more important benefits and covered preventive services of Marketplace plans.
- Dental benefits
- Mental health and substance abuse benefits
- Pregnancy benefits
- Breastfeeding benefits
- Preventive benefits for all adults
- Preventive benefits for children
- Preventive benefits for women
- Birth control benefits
Preview plans and prices in your area and see the benefits that each plan covers.