Coverage + benefits

When you’re in the market for a health plan, pay close attention to coverage and benefits. Coverage is the amount of financial protection you get from insurance. Benefits are the health services your plan covers.

Plan level

Health insurance doesn't cover 100 percent of your costs. Your coverage depends on the type of plan you choose.

Individual and family plans come in five levels. The levels are based on how much you and your health plan will each pay for your health care. Four of the levels are named after metals. The metal levels match different levels of coverage and costs. Use the metal levels to compare plans. A silver plan from Company A should have about the same benefits and coverage as a silver plan from Company B.

Here's an estimate of coverage for the metal plan levels.

Metal Level

Platinum

Insurance pays

90 percent

You pay

10 percent

Premium costs

$$$$

Gold

Insurance pays

80 percent

You pay

20 percent

Premium costs

$$$

Silver

Insurance pays

70 percent

You pay

30 percent

Premium costs

$$

Bronze

Insurance pays

60 percent

You pay

40 percent

Premium costs

$

Plans with higher premiums (like platinum and gold) cover more of the costs when you get care. Those costs can include fees, prescriptions, durable medical equipment, and more. You’ll pay a higher share of those costs if you have a plan with a lower premium (like silver and bronze).

Catastrophic coverage

Catastrophic coverage is the level below bronze. These plans have low premiums but high deductibles. Keep in mind you'll pay all costs until you meet your deductible. After that, your plan will start paying. Catastrophic plans protect you from the costs of a major illness or injury. They offer limited help with routine medical expenses. They're intended for people under age 30. But people over 30 can get a hardship exemption. Find more on hardship exemptions at HealthCare.gov. Or contact your state's health insurance marketplace to see if you qualify.


Benefits always included

All individual and family health plans will help pay for a long list of services. These covered services are called "essential health benefits," and they include:
  • Most same-day services (office visits, outpatient services)
  • Emergency services
  • Prescription drugs
  • Laboratory services
  • Hospitalization (including surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Pediatric services (medical and dental care for children)
  • Rehabilitative and habilitative services and devices (these help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Mental health and substance abuse services
  • Preventive care and chronic disease management

More about covered services

Before you start shopping, here are a few more points to keep in mind about covered services:
  • There's no annual limit on the value of benefits from network providers.
  • You may have to pay part of the cost for any service you get.
  • Preventive services are covered at 100 percent when you use a network provider.
  • There's no cost for vaccines, screening tests, or well-child visits. And many types of birth control are covered at 100 percent.
  • Health plans don't cover everything. Each plan will list non-covered services or exclusions. Cosmetic surgery and experimental drugs are common examples. Your policy document will list your plan's exclusions.

Want to know more?

Find out more about coverage, costs, and other insurance basics.
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