The metal tiers look like a straight line: Bronze cheapest, Platinum dearest, Silver and Gold in between. For one group of households that line is wrong, and the mistake it produces is the most expensive one on the whole Marketplace.
This is the guide about cost-sharing reductions. It carries no figures — the income ranges and the amounts change every year — so treat it as the shape of the thing and check the current numbers on HealthCare.gov.
What the tiers actually mean
Every Marketplace plan covers the same ten essential health benefits. The tier does not tell you what is covered. It tells you how the cost is split between what you pay monthly and what you pay when you use care.
Bronze: lowest premium, highest costs at the point of use. Platinum: the reverse. Silver and Gold in between.
That is the whole of it — for people who do not qualify for cost-sharing reductions.
The exception
Cost-sharing reductions are available only on Silver plans.
If your household income falls within a certain range, and you choose a Silver plan, the plan’s deductible, copays and out-of-pocket maximum are reduced. Not the premium — the amounts you pay when you actually use the coverage.
The effect is real and it can be large. At the stronger levels, a Silver plan with cost-sharing reductions can end up better at the point of use than a Gold plan, while costing less each month.
There is no Bronze equivalent, no Gold equivalent and no Platinum equivalent. Choose any tier other than Silver and the reduction does not apply.
Where it goes wrong
Somebody eligible for a substantial cost-sharing reduction looks at the premium column, sees Bronze is cheaper each month, and picks it. They have saved a modest amount monthly and given up a much larger benefit they never knew they had.
Nobody tells them. The tiers are presented as a ladder, and on the face of it the choice looks sensible.
This is the single reason to have somebody — us, a Navigator, or the Marketplace Call Center — look at your situation before you enroll. Not because the comparison is hard, but because you have to know the reduction exists to look for it.
How to find out whether it applies to you
The Marketplace works it out from your application. When you compare plans on HealthCare.gov after entering your household and income, Silver plans display with the reduction already applied if you qualify.
Two practical points. First, you have to complete the eligibility part of the application, not just browse plans — browsing anonymously shows list prices. Second, look at the actual deductible and out-of-pocket maximum shown on the Silver plans rather than at the tier label.
If Silver’s deductible looks improbably low compared with Bronze, that is the reduction, and it is the answer to the question.
When Silver is not the answer
Cost-sharing reductions do not apply to every household, and where they do not, Silver is genuinely the middle option and may not suit you.
Bronze can be right if you rarely use care, want protection against a catastrophic year, and — this is the part to be honest about — could actually pay the deductible if you had to. A low premium is not a bargain if the deductible is unpayable.
Gold can be right if you have a chronic condition, a planned procedure, or regular prescriptions. Where you know in advance you will use the coverage, paying more monthly and less at the point of use is usually the cheaper year.
Platinum is rarely offered in Kansas, Missouri, Nebraska or Iowa, and rarely the best value where it is.
The order to decide in
- Complete the eligibility part of the application so you can see real prices, not list prices.
- Check whether Silver plans are showing a reduced deductible. If they are, start there.
- Check your doctors by name and your prescriptions by name, on the plans you are considering. In rural counties this decides more than the tier does.
- Ask yourself whether you could pay the deductible on the cheapest plan if you had to. If the answer is no, do not buy it.
Where to get help
HealthCare.gov calculates all of this free. The Marketplace Call Center is on 1-800-318-2596, TTY 1-855-889-4325, at any hour. Navigators and certified application counselors help in person, free, and are not paid by insurance companies — localhelp.healthcare.gov.
If you would rather someone did the comparing, telephone us. It costs you nothing either way, and this is the one page on the site we would most like people to read before they choose.
General information, not advice
This guide describes how Marketplace coverage generally works. It is not advice about your situation, and rules and figures change — verify anything that matters to a decision against HealthCare.gov or the Marketplace Call Center on 1-800-318-2596 (TTY 1-855-889-4325), both free.
Heartland Coverage Partners LLC is not the Health Insurance Marketplace, not HealthCare.gov, and not connected with or endorsed by the United States government. We do not offer every plan available in your area.
