About Insuring Your Health
KHN contributing columnist Michelle Andrews writes the series , which explores health care coverage and costs.
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Q: Will the premiums be more expensive than what is offered on the individual market? How about co-pays, are they comparable?
A: New individual and small-group plans offered both through the health insurance marketplaces and on the private market will all have to offer a package of 10 essential health benefits, including prescription drugs, emergency and hospital care, and maternity care, among other things. They will also have to meet the same standards for consumer cost sharing. So experts don’t expect that premiums on or off the exchanges will be very different.
Here’s how it will work. There will be four types of plans with different levels of consumer cost sharing. In a platinum plan, the insurer will pay 90 percent of covered medical expenses and the consumer will be responsible for 10 percent, on average. In a gold plan, the insurer will pay 80 percent and the consumer 20 percent. Silver plans will pay 70 percent and bronze plans 60 percent. Within each type of plan, insurers will generally have some flexibility to vary deductibles, copayments and coinsurance.
Even though premiums may be comparable on and off the exchanges, there’s a key difference to keep in mind. Consumers who buy a health plan through the online marketplaces may be eligible for premium tax credits there that can substantially reduce the sticker price on their policy.Â
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