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Metal Tiers
Covered CA health plans are divided into four categories known as Metal Tiers. The higher the metal value, the higher the percentage of health care expenses paid by the health plan. The client can choose from many plans within the four Metal Tiers: Bronze, Silver, Gold and Platinum. Individual expenses occur at the time of health care services, for example, visiting the doctor or the emergency room. The health plans that cover the larger percentages generally have a higher monthly premium.
Bronze Plan
The insurance plan pays 60% of the health care costs; clients are responsible for the remaining 40% (a combination of deductibles, copayments, and coinsurance).
Silver Plan
The insurance plan pays 70% of the health care costs; clients are responsible for the remaining 30% (a combination of deductibles, copayments, and coinsurance).
Gold Plan
The insurance plan pays 80% of the health care costs; clients are responsible for the remaining 20% (a combination of deductibles, copayments, and coinsurance).
Platinum Plan
The insurance plan pays 90% of the health care costs; clients are responsible for the remaining 10% (a combination of deductibles, copayments, and coinsurance).
Catastrophic Coverage
The basic coverage plan designed for individuals under age 30 who do not have access to affordable coverage.
Note: Clients covered under the Catastrophic Coverage plan are not eligible for premium assistance, but this plan does meet MEC.
Metal Tier Categories
Note: The Metal Tier Categories chart depicts: Bronze, Silver, Gold, and Platinum, with the corresponding percentages paid by the plan and by the client.
Before choosing a health plan applicants need to determine what type of coverage they need and want. The Metal Tier system offers a range based on overall health and financial status.
- The Platinum and Gold Tiers are more beneficial to applicants that are going to use the doctor a lot. There is a higher premium, but doctor visits and use of medical services cost less in copayments and coinsurance.
- The Silver and Bronze Tiers have a lower monthly premium, but cost more for medical services and doctor visits. Applicants with good health may not need as much care and may find these plans more cost efficient. Cost Sharing Reduction (Enhanced Silver Plan) also offer lower out-of-pocket payments.
- The Catastrophic Coverage plan is available to people younger than 30 or to those who have received an exemption from the Health and Human Services due to unaffordability of coverage or hardship. The plan has a low monthly premium but limited services. Applicants that select this plan are not entitled to APTC.
Sample of Deductible, Copayments, and Out of Pocket Maximum by Metal Tier
|
Key Benefits |
Bronze covers 60% |
Silver covers 70% |
Gold covers 80% |
Platinum covers 90% |
|
Deductible |
$6,000 |
$2,250** |
No Deductible |
No Deductible |
|
Annual Preventive Care Visit Copayment |
No cost |
No cost |
No cost |
No cost |
|
Primary Care Visit Copayment |
$70* |
$45 |
$35 |
$20 |
|
Urgent Care Visit Copayment |
$120* |
$90 |
$60 |
$40 |
|
Emergency Room Copayment |
Full cost up to deductible |
$250 |
$250 |
$150 |
|
Generic Medication Copayment |
Full cost up to $500 deductible |
$15 |
$15 |
$5 |
|
Annual Out-of-Pocket Maximum for One (1) |
$6,500 |
$6,250 |
$6,200 |
$4,000 |
|
Annual Out-of-Pocket Maximum for Family** |
$13,000 |
$12,500 |
$12,400 |
$8,000 |
Chart does not include all medical copayments and coinsurance rates.
*For Bronze plans, the deductible is waived for the first three primary care or urgent care visits. Additional visits are charged at full cost until deductible is met.
**Silver is the only level where the deductible and other costs may be lower based on the household income.
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