The Affordable Care Act (ACA) introduced four metal tier levels of coverage based on the actuarial value for each health plan. The categories have nothing to do with the quality of care provided by the health insurance carrier, but instead represent the share of in-network expenses paid by the health insurance carrier and the percentage of costs paid by the member – you, your employees, or dependents.
So What Are The ACA Metal Tiers?
|Metal Tier||Payment Based on Actuarial Value (Within -4%/+2%)||Member Pays|
|Platinum||Insurance carrier pays 90% of the costs of covered in-network benefits||10% of costs of covered in-network benefits|
|Gold||Insurance carrier pays 80% of the costs of covered in-network benefits||20% of costs of covered in-network benefits|
|Silver||Insurance carrier pays 70% of the costs of covered in-network benefits||30% of costs of covered in-network benefits|
|Bronze||Insurance carrier pays 60% of the costs of covered in-network benefits||40% of costs of covered in-network benefits|
The amount you pay in premium depends on what percentage of covered benefits are paid for by the health insurance carrier. For example, a Platinum plan is typically more expensive, but pays a higher percentage toward covered in-network services. On the other hand, a Bronze plan typically offers lower premiums, and it pays less toward covered in-network services. Costs could be higher in the long term for individuals with a Bronze plan who need a lot of medical care. For small business, group-sponsored health insurance, you (as the employer) select the metal tier to offer to your employees. Some programs, such as the CaliforniaChoice small group private exchange, give you the option to select more than one metal tier. Contact a CaliforniaChoice broker if you want to know more about the ACA metal tiers.
Everyone’s health care needs are different. That’s the idea on which CaliforniaChoice was built 25 years ago. CaliforniaChoice gives people the freedom to choose the health plan that fits their unique needs. That’s because we offer access to eight premier health plans in a single health insurance program.
Knowing the key benefits of each of our plans helps members determine which health plan is right for them. Our CaliforniaChoice plan comparison series takes a closer look at what you can expect from each. This comparison highlights Health Net and UnitedHealthcare.
Established in 1977, Health Net of California is among the state’s largest health insurers. It offers a range of coverage options to millions of California residents. Within the CaliforniaChoice program, you and your employees can choose from 12 different HMO options.
Health Net Benefits Overview
- Predictable costs and easy-to-understand health care benefits
- A choice of provider networks with trusted doctors, medical groups, and hospitals in cities across California
- Access to nurses by phone 24/7
- A Health Net Mobile app that makes it easier for you to get things done
- 24/7 access to telehealth services, with board-certified doctors available by phone, mobile app, or on the web
- Ability to schedule an on-demand doctor house call for sick/urgent care services through Heal.com (in select urban areas)
- Decision Power Wellness Coaching
- Strength and stability: Centene, Health Net’s parent company, is a Fortune 100 company
UnitedHealthcare of California provides access to quality care and helps you manage your family’s health care costs. The insurer’s large California HMO network includes local physicians and health care professionals in communities across the state. Offering a combination of benefits, quality care, wellness programs to help keep you and your family healthier, and award-winning customer service makes UnitedHealthcare the smart choice for your family’s health care coverage needs.
UnitedHealthcare Benefits Overview
- A broad network of quality local doctors and hospitals
- A member website, uhcwest.com, providing online tools and resources
- Health and Wellness programs
- Preventive care for covered family members
- Fitness reimbursement program
The CaliforniaChoice Advantage
With CaliforniaChoice, you can offer your employees coverage from eight health plans, so they can easily find the one that meets their needs. For example, one employee could choose a plan because it offers treatment through its own facilities, while another employee might select a plan because of its diverse provider network across the state. With CaliforniaChoice, they both get what they want — and the options for others to select plans based on their specific needs.
CaliforniaChoice offers more than great health insurance. There are other advantages, too. Like one monthly bill for all of your employees’ coverage, value-added benefits through the Member Value Suite and Business Solutions Suite, and a single email and toll-free phone number for enrollment, eligibility, and customer care.
Visit our blog page to see other comparisons for CaliforniaChoice plans, including:
- Anthem Blue Cross
- Kaiser Permanente
- Oscar Health
- Sharp Health Plan
- Sutter Health Plus
- Western Health Advantage
For additional information about all of the advantages offered by CaliforniaChoice, talk with your employee benefits agent or insurance broker. If you don’t have one, we can help you find one here.
When it comes to something as important as health insurance, having a choice should be a given. CaliforniaChoice offers it. Our program gives you and your employees the freedom to choose from eight different health plans in a single program.
To help guide your decision, we’re highlighting the unique offerings for each of our eight plans. In this comparison, we look at Sharp Health Plan and Western Health Advantage, two regional health plan options available through CaliforniaChoice.
Sharp Health Plan
Sharp Health Plan is the only local, commercial health plan, serving San Diego since 1992. As a non-profit company, Sharp Health Plan gives back to the community by providing access to affordable health care of the highest quality, serving a variety of organizations ranging from small businesses to large employers to municipalities.
Sharp Health Plan Benefits Overview
- HMO Platinum, Gold, Silver, and Bronze plans
- High Deductible Bronze HMO and Health Savings Account (HSA) plans
- High-performance health care network with more than 600 Primary Care Physicians, 1,100 specialists, and 13 local hospitals
- Sharp Nurse Connection, an after-hours nurse advice line
- Global emergency service program operated by Assist America
- Treatment for minor illnesses and injuries available at CVS MinuteClinic® locations nationwide
Western Health Advantage
Since 1996, Western Health Advantage (WHA) has been a reliable health care partner to Northern Californians. Through its HMO network, WHA serves employers and individuals in Sacramento, Yolo, Solano, Napa, Sonoma, and Marin counties as well as parts of Placer and El Dorado counties. Supporting communities is one of WHA’s core values.
Western Health Advantage Benefits Overview
- Affordable coverage with many choices
- A network of thousands of local, trusted doctors and specialists
- Responsive customer service staffed by local, real people
- MyWHA Wellness program with online health and wellness tools
- Discounts on gym memberships
- Nurse24 advice line with registered nurses 24/7
- Worldwide urgent and emergency coverage with Assist America
The CaliforniaChoice Advantage
With CaliforniaChoice, you and your employees have more choice – and the ability to find insurance that meets your unique needs. One of your employees might choose a plan because of its broad PPO network. Another employee might select HMO coverage from a regional or statewide plan. With CaliforniaChoice, they both get what they need – while other employees have the option to choose from six other plans.
There are benefits for you, too – like a single monthly bill for all of your employees’ coverage and single-source administration for enrollment, eligibility, and customer care.
Check back to see additional comparisons on other CaliforniaChoice plans, including:
- Anthem Blue Cross
- Health Net
- Kaiser Permanente
- Oscar Health
- Sutter Health Plan
An employee benefits agent can provide you with more information about the advantages of CaliforniaChoice and the coverage options available. If you don’t already have an agent, you can search for one here.
Born and raised in California, CaliforniaChoice embraces the unique needs of our members. That’s why our employee benefits program includes eight different health plans in a single program – plus options for Dental, Vision, Chiropractic & Acupuncture, and Life and AD&D. We know what’s important to one person may not be important to another. So, we give employees the ability to choose what’s right for their individual or family health care needs.
The CaliforniaChoice plan comparison series takes a closer look at each of the plans in our program and the added options. This comparison snapshot highlights the key benefits of our Dental offerings, specifically SmileSaver Dental HMO and Ameritas Dental PPO.
The tables below show the Dental plans available from SmileSaver and Ameritas.
Your SmileSaver HMO options:
Notes: Copays listed are for services performed by general dentists. Please review the Explanation of Coverage (EOC) for specialist copays. For crowns, the extra cost of high noble metal (gold, etc.) may be charged when used, not to exceed actual laboratory costs of metal.
These are two of your four Ameritas PPO options:
Notes: Please refer to the plan Certificate for specific plan details. Orthodontia (with a 12-month wait and a Lifetime Maximum of $1,000) is included for children starting treatment before their 19th birthday for the PPO 3500. A 12-month Waiting Period applies to Endo/Perio; Waiting Period waived for groups with 10+ employees and 12 months of continuous, uninterrupted Dental coverage on previous plan. For PPO 3500, submit one covered Dental claim each year and the Basic Procedures will advance to the 90% level the following year and 100% on the third year. The Annual Maximum is a Dental/Vision combined benefit; a maximum of which $100 can be applied toward eye care expenses. The Fusion Vision Reimbursement benefit is an added feature of PPO 3500; it offers a $100 annual maximum per calendar year to spend at any eye care provider.
These are the other two Ameritas PPO options:
Notes: Please refer to the plan Certificate for specific plan details. Orthodontia (with a 12-month wait and a Lifetime Maximum of $1,000) is included for children starting treatment before their 19th birthday for the PPO 4000 and 5000 plans. A 12-month Waiting Period applies to Endo/Perio; Waiting Period waived for groups with 10+ employees and 12 months of continuous, uninterrupted Dental coverage on previous plan. For PPO 4000 and 5000, submit one covered Dental claim each year and the Basic Procedures will advance to the 90% level the following year and 100% on the third year. The Annual Maximum is a Dental/Vision combined benefit; a maximum of which $100 can be applied toward eye care expenses. The Fusion Vision Reimbursement benefit is an added feature of PPO 4000 and 5000; it offers a $100 annual maximum per calendar year to spend at any eye care provider.
Dental Rewards® by Ameritas are available to members enrolled in PPO 3500, 4000, and 5000 plans who visit the dentist and use only a portion of their annual maximum benefit in a year. Members can earn additional money toward their next year’s annual maximum benefit. For PPO 4000 and 5000 members, Ameritas Extras include LASIK and Hearing Care coverage. Refer to the plan enrollment materials for details.
For additional information about CaliforniaChoice and available Dental options, talk with your employee benefits agent or health insurance broker. If you don’t already have one, we can help you find one here.