Differences Between Plans
What is covered - These types of plans cover medical and prescription drugs for all who are enrolled. Just like employer plans, they also cover 10 Essential health Benefits:
Ambulatory patient services (seeing a doctor)
Emergency services (a trip to the emergency room)
Hospitalization (staying overnight at a hospital)
Pregnancy, maternity, and newborn care (both before and after birth)
Pediatric services, including oral and vision care (adult and vision coverage are not essential health benefits, and are not included in these plans)
Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
Prescription drugs
Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
Laboratory services
Preventive and wellness services and chronic disease management
How much is covered - There are four categories of insurance plans: Bronze, Silver, Gold, and Platinum. These plans differ based on how you and the plan share the costs of your care, but not on the amount or quality of care you receive. For example, Bronze plans have low premiums but high cost-sharing, Silver is in the middle, and Gold plans have higher premiums than Silver but lower cost-sharing.
What isn’t covered - Although pediatric dental and vision care is included, adults enrolled in these plans will not have dental and vision care covered. You can work with Via Benefits to purchase separate plans for these types of coverage.
Cost-sharing - Each plan will include different cost-sharing amounts described in these terms:
Out-of-pocket maximum: This amount is the most you will pay for health insurance within a plan year.
Deductible: Just like your car insurance, you must spend a specific amount before your health plan begins to pay for your health expenses. Some health plan deductibles can be high - up to several thousand dollars.
Copayment or coinsurance: Payments you make each time you receive medical care after reaching your deductible.
Networks - Most health insurance plans work with a specific group or network of doctors and health care providers. It will cost you less to use providers inside a plan’s network. If you visit doctors outside of your network, you will probably pay more for their services than you would from an in-network doctor.
When researching and choosing coverage, it’s important to familiarize yourself with each plan’s provider network and the rules that govern it, so you know where to go for both routine and emergency care.
All plans provide the same set of Essential Health Benefits as required by law (refer to the list above).