Understanding the Metal Levels in the Affordable Care Act (“ACA”)

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With so many options to consider in small group employer plans, deciding on the best health care plan can be confusing. The affordable care act has made many changes to how the carriers create their plan designs. The insurance plans now use the following category levels: bronze, silver, gold, or platinum, based on how they cover the cost of care.

What do the metal levels mean?

The ACA plans must include a core set of benefits, called Essential Health Benefits (“EHB”), including but not limited to the following: coverage for emergency room care, hospital stays, maternity and newborn care, prescription drugs, and preventive care. Plans and each tear pay different amounts of the total cost of an insured’s care.  For example, bronze plans have the lowest monthly premiums, but the insured pays more when they utilize health care services.  Platinum plans have the highest monthly premiums, but members pay the lowest cost share amounts when they utilize health care services.

The Four Metal Levels:

metal tiers

Bronze: health care plan pays 60%, member pays 40%.

Silver: health care plan pay 70%, member pays 30%.

Gold: health care plan pays 80%, member pays 20%.

Platinum: health care plan pays 90%, member pays 10%.

The metal level impacts not only the premiums, but also how much the member pays for services rendered, such as hospital visits or prescription drugs. Beyond the required essential health benefits, different plans may offer coverage for other services as well. It is important to note, not all metal plans are the same.

 

Important things to consider when selecting a health insurance plan:

  • It is important to look at the health insurance carrier’s network and see if your doctor is a participating provider. Most carriers offer a full network, reduce network, and or a reduced reduce network plan option.
  • It is important to research your prescriptions with the carrier and network you are considering, as the carriers include different prescription formulary lists.
  • If you go to the doctor often or need regular prescriptions, a gold or platinum plan may be a good option to consider. While these plans cost more, the plan pays more of the cost when you utilize the benefits.
  • If you do not go to the doctors very often or take regular prescriptions, a silver or bronze plan may be a good option to consider. These plans cost less per month in premiums, but they also pay less cost when you need to utilize the benefits. So, when selecting silver or bronze, it is important to know that you will pay more out of pocket when seeking medical care than you would if you were insured on gold or platinum plans.

As you can see, there are a lot of things to consider when selecting the right plans to offer your group. At MNJ insurance solutions, we are here to help you evaluate the various plans, networks, and options to meet your needs and budget.

Please contact us at 714-716-4303 if you would like more information.

 

This content is provided for informational purposes only.  While we have attempted to provide current, accurate and clearly expressed information, this information is provided “as is” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy  and completeness.  The information provided should not be construed as legal or tax advice or as a recommendation of any kind.  External users should seek professional advice form their own attorneys and tax and benefit plan advisers with respect to their individual circumstances and needs.

Are You Compliant with your Required Model Notices?

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Model Notices under Health Care Reform

The Affordable Care Act requires group health plans to provide a number of informational notices to employees and other individuals eligible for benefits under the plan.  Model notices that may be used to satisfy certain notice requirements are available from the U.S. Department of Labor.

 

Included is a list of Model Notices and documents that may be required:

Summary of Benefits and Coverage (SBC) and Uniform Glossary:   Group health plans and health insurance issuers offering group health insurance coverage are required to provide participants and beneficiaries a summary of benefits and coverage (SBC) containing specific information about the plan and coverage, as well as a Uniform Glossary of Terms commonly used in health insurance coverage, as several points during the enrollment process and upon request.  The following templates, instructions, and related materials are available for use in connection with coverage beginning before January 1, 2014:

Templates, Instructions, and Related Materials – Currently Applicable (SBCs Before 1/1/2017)

Templates, Instructions, and Related Materials – Proposed (SBCs On or After 1/1/2017)

 

Notice of Coverage Options (Health Insurance Exchange Notice): All employers covered by the Fair Labor Standards Act are required to provide each new full-or part-time employee a written notice with information about a Health Insurance Exchange (Marketplace).  There are two different Notices under this requirement, one notice is for employers who offer coverage, and the other notice is for employers who do NOT offer group coverage.  The initial distribution was required no later than October 1, 2013.  However, in addition to the initial distribution of the Coverage Option Notice, an employer is required to provide it at the time of hiring, within 14 days of the employee’s start date.  The notice may be distributed by first-class mail, or electronically if certain requirements are met.  Model language is available from the DOL:

Notices listed below are categorized by the Grandfathered or Non-Grandfathered Status of your Health Plan.

If your Plan is Grandfathered, the following Health Plan Notices are required:

1.  Grandfathered Model Notice; en español

2.  Dependent to Age 26 Notice (Coverage for Adult Children); en español

3.  Patient Protection Model Notice; en español

4.  Lifetime Limits on Essential Health Benefits; en español

5.  Patient Protections Notice-Prohibition on Rescissions

6.  Internal Claims and Appeals and External Review Decisions

If your Plan is Non-Grandfathered, the above Health Plan Notices (#2-6 are required)

 

Finally, all Plans-Grandfathered and Non-Grandfathered alike-must also provide the following ERISA Notices:

  1. Summary Plan Description (SPD) – An Employer must provide the SPD to plan participants within 90 days of the participant enrolling in the plan.  An updated SPD must be furnished every 5 years if changes are made to SPD information or the plan is amended (otherwise, it must be furnished every 10 years).
  2. Summary of Material Modification (SMM) – Within 60 days of adoption of a material reduction in covered services or benefits (alternatively, notice may be provided with plan information that is furnished at regular intervals of not more than 90 days, if certain conditions are met).
  3. Plan Documents – Copies must be furnished within 30 days of a written request, and the plan administrator must make copies available for examination at its principal office (the DOL can also request any documents relating to the plan).
  4.  WWCRA_Notice – Women’s Health & Cancer Rights Act (WHCRA) Notices – Upon enrollment in a plan that provides coverage for medical and surgical benefits related to a mastectomy, and annually thereafter.
  5. CHIP_Model_Notice(Children’s Health Insurance Program Reauthorization Act);
  6. HIPAA Notice (for self-insured plans) (Contact your agent for assistance);
  7. Medicare Part D Creditable Coverage Disclosure Notice or Non-Creditable Coverage Disclosure Notice – Annually prior to October 15th, upon request, and at various other times as required under the law.  An online disclosure to the Centers for Medicare & Medicaid Services (CMS) is also required annually, no later than 60 days from the beginning of a plan year, and at certain other times
  8. Mental_Health_Parity (Mental Health Parity Act) – Upon request for a plan offering medical/surgical benefits and mental health or substance use disorder benefits
  9. Michelle’s Law Notice – With any notice regarding a requirement for certification of student status under a plan that bases eligibility for coverage on student status (and that provides dependent coverage beyond age 26).
  10. Newborns’ and Mothers’ Health Protection Act Notice – must be included in the SPD for a plan providing maternity or newborn infant coverage.

 

 Other Helpful Documents:
Women’s Health and Cancer Right ACT Payroll Stuffers
Employer’s Tax Guide to Fringe Benefits
Initial COBRA Model Notice (Updated for Healthcare Reform)
COBRA Model Election Notice | en español  (updated for Healthcare Reform)

 

For more information and evaluation of your current benefits, please contact MNJ Insurance Solutions at (714) 716-4303.

 

This content is provided for informational purposes only.  While we have attempted to provide current, accurate and clearly expressed information, this information is provided “as is” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy  and completeness.  The information provided should not be construed as legal or tax advice or as a recommendation of any kind.  External users should seek professional advice form their own attorneys and tax and benefit plan advisers with respect to their individual circumstances and needs.