Benefits, Value and Premium Pricing

Essential Health Benefits

Benefits, Value and Premium Pricing There are 10 essential health benefits that all insurance plans must offer:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Laboratory services
  • Maternity and newborn care
  • Mental health and addiction treatment services
  • Pediatric Services
  • Prescription drugs
  • Preventive/wellness services and chronic disease treatment
  • Rehabilitation services and devices
These Benefits are the minimum requirements for all health care plans. Many plans will offer services in addition to those listed above, but no plan can offer less coverage.

Plan Value

There are four types of plans offered in the Marketplace: Bronze, Silver, Gold, and Platinum. The plans are defined by their actuarial value, which is the average percentage of health care expenses that are covered by the plan. As the actuarial value increases, the plan will pay more towards your health care expenses and lower your out-of-pocket costs for things like deductibles, coinsurance, and copayments.

The drawback of plans that cover more health care and out-of-pocket expenses is a higher monthly premium.

Exact percentages will vary by state, but on average a Bronze plan will cover 60% of covered medical expenses and your share will be the remaining 40%. The actuarial value of each plan is shown below:

90% Platinum
90% Platinum
80% Gold
80% Gold
70% Silver
70% Silver
60% Bronze
60% Bronze

Premium Pricing

Monthly premiums will be primarily based off the items below, no matter which coverage level you choose:

  • Age
  • Smoker or Non-Smoker (some states mandate a “surcharge” if you are a smoker)
  • Current Insurance Company
  • Where you live
  • Number of people enrolling with you (children / spouse)

Helpful Links: