Coverage Basics
We know coverage can be confusing. Do you know about metal levels? Essential health benefits? Know the basics so that you can find the plan that best fits your needs.
What Is a Health Plan?
You buy a health plan each year in case you or your family needs health care. Your insurance carrier pays a part of the cost of health care when you have a health plan.
Why Do I Need a Health Plan?
You never know when you will need to go to the doctor. Having a health plan ensures that you can afford to get medical care when you need it.
Key Terms
Premium
Your premium is the amount you pay each month for your health plan. You must pay your premium even if you do not get any health care services.
Copay
A copay is the amount you pay for a covered health care service. Your copay is due when you receive the service.
Co-insurance
Co-insurance is your share of the cost of a covered health care service. You start to pay co-insurance after you have paid your health plan’s deductible.
Deductible
Your deductible is the amount you must spend on care before your health plan starts to share the cost. Your deductible amount starts over at the beginning of each year.
Out-of-Pocket
Out-of-pocket costs are what you pay for health care. They can include your deductible, co-insurance and copays. Any amount that is not covered by your health plan is an out-of-pocket cost.
Cost-Sharing
Cost-sharing refers to the amount of health care costs that you pay. This term includes deductibles, co-insurance and copays.
Network
The network is the list of providers your health plan covers. In-network providers are approved by your health plan. Out-of-network providers are not approved by your health plan.
Essential Health Benefits
All plans on Washington Healthplanfinder cover essential health benefits. The ten essential health benefits must be covered by law according to the Affordable Care Act.
- Doctor visits and hospital stays
- Trips to the emergency room
- Care before and after your baby is born
- Mental health and substance use treatment
- Prescription drugs
- Services and devices to treat injuries, disabilities or chronic conditions
- Lab tests
- Preventive services
- Management of a chronic disease
- Pediatric care
Covered Preventative Services
Most health plans cover preventive services such as shots and screenings at no cost to you.
Screenings and Counseling
- Depression screening
- Diabetes screening (Type 2)
- Drug and tobacco counseling
- Cholesterol screening
- Colorectal cancer screening
- Diet counseling
- STD and HIV screening
- Wellness visits
Vaccinations
- Hepatitis A and B
- Herpes Zoster
- Human Papillomavirus (HPV)
- Flu shot
- Measles, Mumps, Rubella
- Meningococcal
- Pneumococcal
- Tetanus, Diphtheria, Pertussis
- Varicella
Youth Services
- Behavioral and developmental assessment
- Iron and fluoride supplements
- Screenings and counseling
- Vaccines
- Vision screening
Other Services
- Breastfeeding support
- Mammograms
- Contraceptives
- Domestic violence screening
- STD and HIV screening
Cascade Care: the Best Coverage
Cascade Care plans offer more coverage and ways to save than non-Cascade Care plans. They are only available through Washington Healthplanfinder.
There are two types of Cascade Care plans: Cascade plans and Cascade Select plans. Cascade Select plans must meet higher standards.
Cascade Care plans offer more coverage for less cost. They cover more services than most plans before you must meet the deductible. This includes primary care, mental health services, generic drugs and more.
You also save on out-of-pocket costs. On average, your deductible is $1,000 less when you choose a Cascade Care plan.
Metal Levels
Metal levels are categories of health plans. They group plans by how much of the cost of care they cover. Often, a lower premium means the cost of care will be higher, and vice versa.
All metal levels cover essential health benefits.
How to Choose a Metal Level
There are a few things to consider when choosing a metal level plan. Keep in mind that these levels do not pertain to quality of care, only the amount of coverage.
Choose a Bronze plan if you rarely use your coverage.
If you do not go to the doctor or use prescriptions often, a Bronze plan may be a good fit. These plans cost less per month but cover less of the cost when you need care. In most cases, Bronze plans do not qualify for savings.
Choose a Silver plan if you regularly use your coverage and qualify for savings.
You may want to choose a Silver plan if you qualify for premium or out-of-pocket cost savings. These savings can be applied to Silver plan costs.
Choose a Gold plan if you frequently use your coverage and qualify for savings.
If you expect to go to the doctor or use prescriptions often, a Gold plan may be a good fit. These plans cost more per month but cover more of the cost when you need care. Savings can also be applied to Gold plans.
View our Metal Level Guide for more details.
Get to know your plan!
Once you enroll, it’s time to use your coverage. You can use your coverage to:
- Get prescriptions
- Go to the doctor
- Get emergency care
- And more!
Learn more about how your plan works once you are covered.
