Long Island NY Health Insurance Metal Plans Explained

August 6, 2014



Long Island NY Health Insurance Metal Plans Explained

Under the Affordable Care Act (ACA aka Obamacare) all insurance plans in the Small Group and Individual markets must fall within the 4 accepted ‘Metal Plans’. These Metal plans are called Platinum, Gold, Silver, and Bronze. These plans can be purchased through licensed brokers through EITHER of two avenues: the state exchange called NY State of Health (NYSOH), or directly through the carriers themselves.

In order to determine which ‘Metal’ plan would be best for you, let’s first review some basic plan definitions you must know.

PREMIUM: the amount you pay for the coverage each month is called the premium. You pay this whether or not you go to the doctor, visit the hospital or buy prescription medications.

DEDUCTIBLE: the amount you have to pay for covered services before your insurance starts to pay. For instance, if you have a $1,000 deductible, you will pay 100% of your health care expenses until the amount you have paid reaches $1,000 (aka ‘meeting your deductible’). After you ‘meet your deductible’, some service might be covered at 100% while others would require you to pay coinsurance OR a copayment. These terms are explained below.

COPAYMENT (aka “copay”): the fixed dollar cost that you pay for health care services. Typically, you will have different copayment amounts for different types of service, such as a $25 copayment for a doctor’s office visit or a $150 copayment for an emergency room visit. Most of the time, any copayments you make do not count towards meeting your deductible. Copayments typically are paid ‘in lieu of’ coinsurance…meaning in most cases once you have met your deductible, you will pay EITHER coinsurance OR a copayment but never both.

COINSURANCE: This is your share of the costs of a given health care service. It is figured as a fixed percentage of the total charge for a service, such as 10% or 30%. Coinsurance kicks in after you’ve met your deductible. For example, assume you’ve already met your $1,000 deductible and your plan’s coinsurance is 10%. If you have a hospital charge of $1,000, your share of the costs would be $100 (10% of $1,000). If your coinsurance was 30%, your share would be $300.

MAXIMUM OUT OF POCKET – MOOP (or out-of-pocket limit): the most you pay during a policy period (typically a calendar year) before your plan starts to pay 100% of the allowed amount. While all ‘Metal Plans’ vary in their MOOP limits, even the lowest benefit Bronze plans in 2014 limit the MOOP to $6,350 for individuals and $12,700 for families. COPAYS, COINSURNACE, DEDUCTIBLES and DRUG COPAYS all count towards meeting the MOOP. Premiums and non-covered services do NOT count towards MOOP.

ESSENTIAL HEALTH BENEFITS: No matter what plan you choose – Bronze, Silver, Gold, or Platinum – the same set of 10 Essential Health Benefits will be covered:

1. Care at a doctor’s office

2. Emergency services

3. Hospital care

4. Pregnant mother and baby care

5. Mental health and addiction treatment

6. Prescription drugs

7. Rehab and skill development services and devices

8. Lab services

9. Prevention & wellness services and long-lasting disease management

10. Dental and vision care for children

The Essential Health Benefits are the minimum requirements for all plans; however certain plans will offer additional coverage, but no plan can offer less.

ACTUARIAL VALUE: All Metal Plans are differentiated based on their actuarial value: the average percentage of health care expenses that will be paid by the plan. The higher the actuarial value (i.e. Gold and Platinum), the more the plan will pay towards your health care expenses and, therefore, the lower your out-of-pocket costs for things such as deductibles, copays, coinsurance and MOOP. Actuarial values for plans are as follows:

Platinum:            90%

Gold:                  80%

Silver:                70%

Bronze:               60%



Deciding which plan is best for you can be a challenge. You should go about your decision based on these questions:

Do I have the resources to cover the MOOP? This is your worst case scenario for the year, so if you are unable to afford this amount, consider purchasing a higher value plan.

Am I a fairly healthy person? Those that are fairly healthy or do not visit doctors often are the ones who can afford to purchase a lower value plan and play the odds they will not need to utilize services and therefore can save premiums. Use those savings to build up an account to tap should you one day need to utilize services to help offset the deductibles and MOOP you would incur.

Am I one who utilizes services often? If so, a higher value plan might help lower overall spending as it will cover services sooner, with less out-of-pocket costs. Combine the higher premiums and lower out-of-pocket costs vs a lower priced plan with higher out-of-pocket costs to see which might work best. While this is difficult to do, you might wish to go with the theory that higher utilization people will benefit from higher valued metal plans.

Do I enroll through NYSOH or directly with the insurance company? – This will depend on your income. HOUSEHOLD income for one enrolling family member needs to be UNDER $45,960 in order to benefit from enrolling through NYSOH. If your income is above this level, it is much easier to enroll with the carrier directly. These income limits change depending on the number of ENROLLING members per family. Premiums will also be affected for incomes below the above threshold as you might qualify for help in paying for your premiums.

As licensed Health Insurance Brokers serving all of Long Island and NYC, Peak Advisors is also certified on the NYSOH marketplace as well as all carriers directly. We can help you decide your best course of action in applying for either individual health insurance or small group health insurance. NY State law oversees insurance premiums, and using a broker does not affect the premium paid for the plan and no plan can be purchased through another distributor or from the carrier directly with a different commission amount or at a lower cost. Because of this, Brokers provide a free service to individuals and small businesses that should be taken advantage of.

Call or e-mail us today to discuss your options!

631-207-1800 or info@peakinsuranceadvisors.com