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Any health insurance plan sold
through New York State of Health
will need to include coverage for
medical services in the following 10
categories in accordance with the
Affordable Care Act legislation:
Ambulatory patient services, such as
doctor’s visits and outpatient
Maternity and newborn care
Mental health and substance use
disorder services, including
behavioral health treatment
Rehabilitative and habilitative
services and devices
Preventive and wellness services and
chronic disease management
Pediatric services, including oral and
States will also play a role in
determining which minimum
essential benefits will be covered
under the Affordable Care Act.
What Is the Silver Plan?
The Affordable Care Act, sometimes called the ACA, defines four new
types of health insurance plans for individuals and families. The four
types of plans, ranked from most expensive out-of-pocket costs for
consumers to the least, are: Bronze, Silver, Gold, and Platinum. All of
these plans will all offer the same minimum of benefits. These minimum
benefits are determined by the federal and state government and must
be included in a plan regardless of any additional benefits the plan
decides to include.
For an insurance company to participate in an exchange, i.e. a state-run
marketplace offering Affordable Care Act plans, the company does not
have to offer all four plans but it must offer at least the Silver Plan and
also the Gold Plan.
The Silver Planhas lower out-of-pocket costs than the Bronze Plan but
higher out- of-pocket costs than both the Gold and Platinum Plans. All
Silver Plans share the same minimum health benefits but the way they
charge out-of-pocket costs can differ significantly.
What Are The Silver Plan’s Out-of-Pocket
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Based on an average person’s expected use of healthcare services, Silver Plans have the insurance company pay 70% of covered healthcare
expenses. The remaining 30% of expenses are paid by plan out-of-pocket. These out-of-pocket expenses include deductibles, copayments, and
coinsurance. However, the plan’s monthly premium is not included as one of these out-of-pocket costs.
Silver Plan Example A
Silver Plan Example B
30% of costs of enrolled population
30% of costs of enrolled population
Consumer Out-of-Pocket Costs
The table below illustrates how out-of-pocket costs can differ among three insurance companies that offer a Silver Plan.
As you can see in the table, deductibles and coinsurance can vary significantly among Silver Plans. Even though both Silver Plan examples cover
70% of medical costs, this coverage applies to the entire enrolled population. Some individual may receive more cost sharing and some less
depending on the medical services used. The out-of-pocket costs also assume enrollees are using doctors and facilities approve by the plan. If you
use a healthcare provider who is not approved, you could pay considerably higher costs and those costs might not apply towards the maximum out-
of-pocket expenses you can pay in a calendar year.
There are also special versions of Silver Plans with lower out-of-pocket costs for people whose income qualifies them for enrollment. These Silver
Plans are known as "Cost-Sharing Reduction" plans or CSR plans.
Tax Credit for Individuals & Families
The Affordable Care Act provides federal tax credits to people with middle incomes and low incomes whether they are buying individual or family
insurance plans. The tax credit is based on the Silver Plan’s costs. If you are wondering what the tax credit is and how to determine if you are eligible
then visit our Affordable Care Act Tax Credit page.
Silver Plans for Small Business Employees
Small business can purchase group versions Silver Plans as well as the Bronze, Gold, and Platinum plans. These plans have the same benefit
requirements but small group plans have different limits on deductibles. The maximum deductible for an individual enrollee is $2,000 in 2014 while the
maximum deductible for a family enrollment is $4,000.
Companies with 50 or more full-time equivalent employees that fail to provide health insurance that covers at least 60% of the covered medical
services face a penalty. This 60% minimum percentage means that an entry-level Bronze Plan could satisfy the requirement. Another aspect of the
coverage requirement is that it must be affordable, affordability understood as an employee premium not exceeding 9.5% of household income.
Companies with fewer than 50 full-time equivalent employees are exempted from the health insurance requirements. A full-time employee is one who
works at least 30 hours a week. Two part-time employees working 15 hours a week equal one full-time equivalent employee.
Frequently Asked Questions
What does it mean when a Silver Plan is a benchmark plan?
A state insurance exchange uses the premium amount from a selected Silver Plan within the state to serve as the basis for subsidy calculations. The
Silver Plan selected is the Silver Plan in the exchange with the second lowest premium. Even if a subsidy-eligible person chooses a Bronze, Gold, or
Platinum plan, his or her subsidy amount is calculated based on the benchmark Silver Plan.
Do Silver Plans have more benefits than a Bronze Plan?
Silver Plans have the same benefit requirements as Bronze Plans. These benefit requirements are known as the Essential Health Benefits. An
insurance company can choose the add benefits to a Silver Plan as well as any of the other new Affordable Care Act health plans. However, adding
benefits are not required and does not distinguish a Silver Plan from a Bronze Plan, Gold Plan, or Platinum Plan.
Do Silver Plans cost more than Bronze Plans?
The answer is tricky. On average, Silver Plans should have higher premiums than Bronze Plans since Silver Plans pay a higher percentage of medical
costs. However, prices vary among insurers and prices vary among regions so it is theoretically possible that there can be a specific Silver Plan that is
less expensive than a specific Bronze Plan but this is expected to be an exception rather than the rule.
Can I get a Cost-Sharing Reduction (CSR) health plan that is not a Silver Plan?
No. CSR health plans are Silver Plans and enrollees must meet income eligibility criteria. To learn more, visit our Cost-Sharing Reduction (CSR)
Health Insurance Page.