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All non-grandfathered Individual and small group markets Marketplace plans must provide the following four categories that limit the maximum out of pocket costs. These categories are sometimes also referred to as "metal levels". The categories are determined by the acturial value (AV) of the plan design. AV is calculated based on the average portion of the cost of providing EHB that is determined to be paid by the Health Insurance plan for a standard population. The AV calculation is expressed in percentages. Usually the higher AV, the more enrollees pay in monthly premiums and the less out-of-pocket expenses of the insured.
(1) Platinum - 90% AV (The Health Insurance Plan pays on average approximately 90% of the cost of all EHB)
(2) Gold - 80% AV (The Health Insurance Plan pays on average approximately 80% of the cost of all EHB)
(3) Silver - 70% AV (the Health Insurance Plan pays on average approximately 70% of the cost of all EHB)
(4) Bronze - 60% AV (the Health Insurance Plan pays on average approximately 60% of the cost of all EHB)
There are some limitations on a qualified individual changing plan categories. Health Insurance issuers are required to offer Gold and Silver plans if they want to sell plans through a Marketplace.
There are out of pocket limits for all non-grandfathered health plans. Deductibles, coinsurance, and copayment cannot be applied to certain recommended preventive services.
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