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Health Insurance Glossary

Definitions for common health insurance terms

metal plans

DEFINITION: One provision of the ACA is to standardize and improve individual health insurance policies. This was done by creating a “metal” ranking for individual policies, based on their actuarial value (the percentage of costs that the plan pays before the insured has met the out-of-pocket maximum. After that point, all plans pay 100 percent of covered costs).

On a Bronze plan, the insured pays roughly 40 percent of costs. On a Silver plan, it’s 30 percent; Gold, 20 percent; and Platinum, 10 percent. But those average are across the entire population of enrollees – for an individual person, the percentage of costs covered by the plan in a given year will depend on how much health care the person needs. A person with significant claims may pay only a tiny fraction of the total costs, whereas a person who only has a few doctor visits in the year may pay all or most of the costs, depending on the plan structure.

The metal designations apply to plans both in and out of the exchanges. Regardless of the metal level, non-grandfathered private plans cannot have out-of-pocket maximums that exceed $6,850 for an individual and $13,700 for a family in 2016. That will increase to $7,150 and $14,300 in 2017.