What does it all mean? The first step in understanding the ACA is deciphering its vocabulary.
Any medical expense not reimbursed by an insurance provider is considered an out-of-pocket cost. This includes the premium—the monthly amount you pay to your insurance provider regardless of whether you’ve utilized any medical services or not—as well as the deductible, the amount bene?ciaries must pay for covered health services before an insurance company pays anything.
Other costs include co-payments and co-insurance—costs you pay for medical services after reaching your deductible—and the out-of-pocket maximum, the cap on costs for medical services a bene?ciary is responsible for paying in a given year.
Depending on your income, you might be eligible for discounts that can lower your out-of-pocket expenses like deductibles, co-payments and co-insurance. The maximum amount a marketplace bene?ciary could be required to pay for medical care in a given year is also lowered if they qualify for cost-sharing reductions, which are sometimes referred to as extra savings.
Once they meet this out-of-pocket maximum, their insurance provider will then pick up the tab for 100% of all covered services.
Marketplace bene?ciaries have the option to enroll in ?ve categories of coverage: bronze, silver, gold, platinum and catastrophic.
The ?rst four are known as the metal tiers. Each offers the same routine medical services as the others but at different levels of cost to the consumer. The ratio of how much you pay out-of-pocket versus how much your insurance pays varies from tier to tier.
The general consumer-versus-provider percentage split is: bronze (40/60), silver (30/70), gold (20/80) and platinum (10/90).
The ?fth category, catastrophic health plans, offer low monthly premiums (the trade-off being a higher deductible). As the name implies, this category is really more worst-case scenario coverage in the event of serious illness or injury, as enrollees will be responsible for paying most of their routine medical expenses out of pocket. Only those under 30 years old or have a hardship exemption can sign up for catastrophic coverage.
Essential health bene?ts
All marketplace plans, no matter the coverage category, must provide bene?ciaries access to 10 basic types of medical services known as essential health bene?ts.
These include ambulatory patient services; emergency services; hospitalization; pregnancy, maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative 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 market place 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 con?rm they are covered prior to picking a plan.
While all marketplace health plans cover the same routine medical services, the doctors and hospitals providing these services in a given network will vary from plan to plan.
Getting to know your network is important because seeking medical care outside of it comes at additional costs above the out-of-pocket expenses you already pay for insurance.