Key Components of Plan Selection
Plan Generosity
Premium costs and the generosity of coverage vary with the metal level of the plan you select. Your state
marketplace website may have a cost calculator that helps you to estimate your premium and out-of-
pocket costs under various plan options.
If you have a chronic condition, take several prescriptions, or need an expensive medical treatment in the
near future, selecting a gold or platinum plan may be a better choice for you. Your cost sharing and total
out-of-pocket spending may be lower under such a plan, though premiums may be higher. You will need
to balance your need for health care services with the amount you want to pay in premium and out-of-
pocket costs.
Individuals who expect less extensive health care needs may prefer to purchase less expensive bronze or
silver plans. Importantly, people who receive cost-sharing reductions must enroll in the silver plan
variation that applies to their income level to receive the benefit of the cost-sharing reduction.
Once you decide the level of coverage that is right for you, there are other decisions to make. Each state
will have several plans at each metal level. The next three sections of this toolkit will help you sort
through other factors to consider when enrolling in a marketplace plan—covered benefits and costs,
provider networks, and coverage of prescription medications.
Covered Benefits and Costs
It is important to enroll in a plan that covers the health care services you and your family utilize most
frequently. Plans are required to cover services across a variety of categories, but the specific kinds of
care you need may not be included in the benefits of every health plan, even if you are comparing plans in
the same metal level. You will also want to understand the cost-sharing structure under your plan—the
deductible, copayments, and coinsurance. Finally, you should identify any limits on covered items or
services, such as the number of times you can receive a recurring treatment or whether you need plan
authorization before receiving a covered service. You can use the Checklist for the Health Insurance
Marketplace to help you gather the information you should consider to select the plan that meets your
needs.
Marketplace websites will display each plan’s benefits in a standardized way so that you can compare
across your options more easily. The plan also must provide information about the services that are
excluded from coverage. If you or your immediate family members have specific health care needs, you
should narrow your options to the plans that cover those specific services. If you or your family receives
health care items or services that are not covered by the plan, you will have to pay for the entire cost of
that care.
In most states, plans within the same metal level will vary in cost-sharing requirements. Marketplace
websites will include a summary of deductibles, copayments, and coinsurance for different types of
covered services. You may have a single deductible for all care or you may have separate deductibles, one
for medical services and a second deductible for prescription drug costs. For example, one silver plan
could require you to pay the first $1,000 of your care out-of-pocket; another may have a $500 deductible