Benefits coverage reference guide

Easy-to-understand chart helps you compare health plan options

Deciding on the best type of health insurance can be confusing – especially with so many options to consider. But now plans are easier to compare by looking for clearly marked medallions. Health care reform requires plans in the individual and small-group markets to meet certain coverage standards, which are represented by metal levels: Bronze, Silver, Gold or Platinum. The levels indicate the actuarial value of the plan, which is the percentage of Essential Health Benefits (EHB) the plan pays. Take a look at a few key details to compare coverage levels and decide on a plan that best meets your needs and your budget.


  Bronze Silver Gold Platinum

Covered Benefits

60% of Essential Health Benefits (EHB)

Preventive Services

70% of Essential Health Benefits (EHB)

Preventive Services

80% of Essential Health Benefits (EHB)

Preventive Services

90% of Essential Health Benefits

Preventive Services

Co-insurance
Cost to you for health services you will be responsible for:

Approximately 40% of all EHB up to your out-of-pocket limit

Approximately 30% of all EHB up to your out-of-pocket limit

Approximately 20% of all EHB up to your out-of-pocket limit

Approximately 10% of all EHB up to your out-of-pocket limit

You will not need to pay any portion for preventive services if you receive these services from a provider within your plan’s network. However, you may need to pay for any limits or exclusions. Limits may include number of refills for certain drugs, number of visits to certain specialists, and number of days covered for certain benefits.

Cost-share subsidy eligible?
Lower co-pays and other out-of-pocket expenses

No. This plan is not eligible for cost-share subsidies that could lower your out-of-pocket expenses.

Yes. If your income is between 100% and 250% of the Federal Poverty Level, you may be eligible for cost-share subsidies to lower the cost of health services.

Note: If receiving cost-share, a higher actuarial level plan is automatically assigned to you based on your income to lower the cost to you.

No. This plan is not eligible for cost-share subsidies that could lower your out-of-pocket expenses.

No. This plan is not eligible for cost-share subsidies that could lower your out-of-pocket expenses.

Premium subsidy eligible?
Lower cost premium.

Yes. If your income is between 100% - 400% of the Federal Poverty Level, you may be eligible for a premium subsidy to help lower the cost of your premium, which is the monthly payment for health coverage.

Risk

This plan offers the minimal level of health protection. 

You will not need to pay for preventive services, but you will need to plan for a very high amount of financial risk and out-of-pocket costs.

This plan offers the benchmark level of health protection. It is still a lower amount of coverage than the average employer-provided coverage in 2013.

You will not need to pay for preventive services, but you will need to plan for a high amount of financial risk and out-of-pocket costs.

This plan offers coverage equivalent to the average employer-provided coverage in 2014.

You will not need to pay for preventive services, but you will need to plan for a moderate amount of financial risk and out-of-pocket costs.

This plan offers coverage above the average employer-provided coverage in 2014.

You will not need to pay for preventive services, but you will need to plan for a low amount of financial risk, as well as 10% of out-of-pocket costs.

 

Example
The cost to you – after the deductible for an unexpected accident or illness could be:*

Broken leg:  $4,000

Heart attack: $26,000

Broken leg: $3,000

Heart attack: $19,500

Broken leg:  $2,000

Heart attack: $13,000

Broken leg:  $1,000

Heart attack: $6,500

Uncover the real cost of an injury or illness: aflac.com/realcost.

Protect your finances

Protect your finances in the event of the unexpected. Learn more about supplemental insurance: aflac.com/individuals/policies.aspx

* Please note that the potential out-of-pocket costs are distinct from the out-of-pocket limits set by the IRS, discussed in more detail below. The out-of-pocket costs are intended to reference potential additional expenses, such as rent or mortgage payments, child care costs, utility bills or transportation to and from treatment facilities.

Definitions and/or more information:

Essential Health Benefits: A set of health care categories that must be covered by certain plans. They include: 1

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

For more information visit: https://www.healthcare.gov/glossary/essential-health-benefits/

For more information visit: http://www.healthcare.gov/glossary/e/essential.html

Out-of-pocket limit: The out-of-pocket limits established by the IRS for 2014 are $6,350 for individual coverage and $12,700 for family coverage. These limits apply only to covered benefits, and so if an individual or family incurs expenses for non-covered benefits, these will not count towards their out-of-pocket limit, adding to potential unexpected costs.

Preventive Services: Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.1 For more information visit: http://www.healthcare.gov/law/features/rights/preventive-care/index.html

Premium: The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.1

Federal Poverty Level: A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits.1

Supplemental Insurance: Low-cost supplemental insurance such as accident, hospital, and disability insurance will pay you cash for illnesses or injuries, and will help you cover out-of-pocket costs that major medical insurance was never intended to cover.

Source:

1 healthcare.gov/glossary

Note: This chart has been shortened for your optimal online experience. Click download the article to download the full PDF.

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