Exemptions to the Individual Mandate
There are some cases where there is no penalty to not having coverage.
To help consumers compare costs, plans available through the Health Insurance Marketplace fall into four tiers. Or four levels of cost-sharing generosity that each plan includes:
Bronze Level – The plan must cover 60% of expected costs across a standard population. This is the lowest level of coverage.
Silver Level – The plan must cover 70% of expected costs across a standard population.
Gold Level – The plan must cover 80% of expected costs across a standard population.
Platinum Level – The plan must over 90% of expected costs across a standard population. This is the highest level of coverage.
Catastrophic plans are also offered and will cover the same services. But, their coverage will be less generous than the Bronze level plans.
A catastrophic plan may be less expensive option for those who are eligible: only
Young adults under 30 or
Individuals who have a hardship exemption from the individual mandate
Premium tax credits and cost-sharing reductions are not available for catastrophic plans
Beginning in 2015 they cannot be used with Health Savings Accounts (HSAs).
Stand-alone dental plans are also available through the Health Insurance Marketplace.
The tiers are a way to categorize plans based on actuarial value*.
Plans within each tier have a similar actuarial value, even if they cover benefits differently or have different cost-sharing.
Even though all plans in a tier must cover essential health benefits, the details of their coverage may be different.
For example: how many physical therapy visits are covered or which prescription drugs are covered
Some plans may offer benefits in addition to the essential health benefits.
Actuarial value compares how much the insurance company will pay versus how much you will pay for health care costs.
The percentage the plan pays depends on the cost-sharing details:
Such as: how much out-of-pocket the consumer pays for deductibles, coinsurance, copayments, and the out-of-pocket limits.
The percentage is an estimate of what the plan will pay for all policyholders.
Your individual benefits may be more or less.
It doesn’t give any other information about a plan that may be important to a particular person or affect their costs.
It doesn’t tell you how broad or narrow a plan’s provider network is
It doesn’t tell you the quality of the provider network
It doesn’t tell you about the plan’s customer service and support
It doesn’t tell you how broad or narrow the drug formulary is, or the premium levels.
All of this information is important for consumers to consider when they choose a plan.
See www.healthcare.gov/how-do-i-choose-marketplace-insurance for additional information for consumers about actuarial value.
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