The New Health Insurance Exchanges: Types of Plans and Covered Services

The New Health Insurance Exchanges: Types of Plans and Covered Services

Eileen St. Pierre, The Everyday Financial Planner

Individual health insurance plans in the new health insurance exchanges (the Marketplace) will be sold and run by private companies.  If you decide to enroll, you will have guaranteed coverage and renewability, regardless of pre‐existing conditions, your sex, or age.  According to the Center for Medicare & Medicaid Services, 129 million people have pre-existing conditions.

Covered Services

Every qualified health plan offered in the Marketplace will cover a core set of benefits called Essential Health Benefits:

  • Ambulatory services
  • Emergency services
  • Hospitalization
  • Laboratory services
  • Maternity and newborn care
  • Mental health and substance use disorder services
  • Pediatric services, including oral and vision care (dental services may be stand-alone plans)
  • Prescription drugs
  • Preventative and wellness services, and chronic disease management
  • Rehabilitative services and devices

Providers are not required to offer adult dental plans.  Some plans may cover additional benefits.  You may have to see certain providers or use certain hospitals.

Types of Plans

Premiums, co-pays, and coinsurance will vary based across plans.  Exact numbers for plans offered on federally-run exchanges will not be released until October 1.  If you live in a state that is running its own exchange, check its website to see if cost figures have been released.

There will be four types of plans:

  1. Bronze – The cheapest plan; you pay 40% of costs on average in addition to the monthly plan premium
  2. Silver – Plan pays 70%, you pay 30% + monthly premium
  3. Gold – Plan pays 80%, you pay 20% + monthly premium
  4. Platinum – The most expensive plan; you pay only 10% of costs on average + monthly premium.

Approved insurance providers are required to offer Silver and Gold plans.  They may offer Bronze and Platinum plans.

A Catastrophic Health Plan will also be available to individuals age 30 or younger, and those individuals who obtain hardship waivers.  This is a high-deductible plan.

  • These plans cover 3 annual primary care visits and preventive services at no cost.  Enrollees pay out-of-pocket for other expenses.
  • After the deductible is met, they cover the same set of Essential Health Benefits that other Marketplace plans offer.
  • These plans are not eligible for tax credits and cost-sharing reductions.
  • Each member of the family must meet eligibility requirements to purchase.

Visit my Health Care Reform page for more information.

My next column will describe the tax credits available to help lower monthly premiums and cost-sharing reductions for those who qualify.