Understanding Individual Health Insurance Plans

Choosing the right health insurance plan can feel overwhelming, but keeping a few key factors in mind can simplify the process.

1. The 4 “Metal” Categories
Health insurance plans are divided into four categories: Bronze, Silver, Gold, and Platinum. These categories indicate how you and your insurance plan share costs, but they don’t reflect the quality of care or services offered.

• Bronze: Lower premiums, higher out-of-pocket costs; good for minimal health needs.
• Silver: Moderate premiums and out-of-pocket costs; often a balance between cost and coverage.
• Gold: Higher premiums, lower out-of-pocket costs; ideal if you expect frequent medical care.
• Platinum: Highest premiums, lowest out-of-pocket costs; suited for those needing extensive care.

2. Total Health Care Costs
Your expenses include two main components:

• Premiums: A fixed monthly payment, even if you don’t use any services.
• Out-of-Pocket Costs: Expenses you pay when you receive care, like deductibles, copayments, and coinsurance.

When comparing plans, consider both your monthly premium and your potential out-of-pocket costs based on your healthcare needs.

3. Plan and Network Types
Health insurance plans also vary by network type, which affects the doctors and facilities you can use:

• HMO (Health Maintenance Organization): Requires you to use in-network providers and get referrals for specialists.
• PPO (Preferred Provider Organization): Offers more flexibility to use out-of-network providers, often at a higher cost.
• POS (Point of Service): Combines HMO and PPO features, requiring referrals but allowing some out-of-network care.
• EPO (Exclusive Provider Organization): Limits coverage to in-network providers except in emergencies.

4. Don’t Forget About Quality
While the metal categories describe cost-sharing, plans may also vary in the quality of care and services provided. Look for quality ratings or reviews to help make an informed decision.

By understanding these key elements, you’ll be better equipped to choose a plan that fits your budget and healthcare needs.

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How Costs Are Shared Between You and Your Insurance Plan

Plan Category	The insurance company pays	You pay
Bronze	60%	40%
Silver	70%	30%
Gold	80%	20%
Platinum	90%	10%

Which metal category is right for you?

Bronze Health Insurance Plans
Bronze ACA Marketplace plans typically have the lowest monthly premiums but the highest deductibles and out-of-pocket maximums. Typically, the plan pays 60%, while the insured pays 40%. The deductible is generally high.

What to expect:

• Lower monthly premiums
• Higher deductibles and out-of-pocket maximums
• Copays may apply to primary care physician (PCP) visits, specialist visits, urgent care, outpatient mental health and sometimes bloodwork and physical therapy
• Expenses beyond copays typically apply towards your deductible and out-of-pocket maximum
• Many health savings account (HSA) plans are categorized as Bronze
• Some health insurance plan carriers offer Bronze plans with a $0 deductible, but these may have higher copays. These plans can be a good option if you anticipate an upcoming outpatient procedure

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Silver Health Insurance Plan
Silver ACA Marketplace plans typically offer a balance between monthly premiums and out-of-pocket costs. Typically, the plan pays 70%, while the insured pays 30%. The deductible is generally moderate.

What to expect:

• Higher monthly premiums than Bronze plans

• Lower copays and deductibles than Bronze plans

• Out-of-pocket maximums are usually similar to Bronze plans

• You may qualify for Cost-Sharing Reductions (CSRs) based on your income, which can significantly lower your out-of-pocket costs

• Silver plans are the only tier eligible for CSRs

• With Silver with extra savings plans, the plan pays between 73%-96%, while the insured pays for 6%-27%, depending on how much savings the insured qualifies for

• With Silver with extra savings plans, the deductible is generally low

• Silver plans are a popular choice for those who qualify for CSRs or who want lower deductibles compared to Bronze plans

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Gold Health Insurance Plans

Gold ACA Marketplace plans typically have the highest monthly premiums but the lowest out-of-pocket costs. Typically, the plan pays 80%, while the insured pays 20%. The deductible is generally low.

What to Expect:

• Highest monthly premiums
• Lowest copays, deductibles and out-of-pocket maximum
• Gold plans are a good option for people with higher medical needs, those who take expensive medications (Tier 3 or higher) or those who prefer more comprehensive coverage
• Gold plans often cover Tier 3 and Tier 4 medications with a copay or after the deductible is met
  

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The ACA Marketplace also offers Platinum plans, which pay 90%, while the insured pays 10%. The deductible is generally low.

Lower Your Premium Based on Income
No matter which metal category you choose, your monthly premium can be significantly reduced depending on your income. When you complete a Marketplace insurance application, you'll discover if you qualify for savings.

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When to Enroll in an Individual Health Insurance Plan
You can purchase or modify an individual health insurance plan during the open enrollment period. For most states, open enrollment runs from November 1 to January 15 each year. States with their own exchanges often have extended open enrollment windows.

For 2025 plans, some states have expanded open enrollment periods:

California: Nov. 1 to Jan. 31
D.C.: Nov. 1 to Jan. 31
Massachusetts: Nov. 1 to Jan. 23
New York: Nov. 1 to Jan. 31
Rhode Island: Nov. 1 to Jan. 31

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No matter which metal category you choose, your monthly premium can be significantly reduced depending on your income. When you complete a Marketplace insurance application, you’ll discover if you qualify for savings.

 

You can purchase or modify an individual health insurance plan during the open enrollment period. For most states, open enrollment runs from November 1 to January 15 each year. States with their own exchanges often have extended open enrollment windows.

For 2025 plans, some states have expanded open enrollment periods:

 

Outside of open enrollment, you can only buy individual health insurance if you experience a qualifying life event that triggers a Special Enrollment Period (SEP). SEPs last for 60 days following the qualifying event.

Common qualifying events include:

 

If you qualify for a SEP, it’s important to act quickly to secure coverage during the 60-day window.