Understanding Silver Plan Health Insurance

Benefits of Silver Healthcare Plans

All metal level plans, including Silver plans, must cover essential health benefits mandated by the ACA, including:

• Ambulatory patient services (outpatient care received without being admitted to a hospital)
• Emergency services
• Hospitalization (surgery and overnight stays)
• Pregnancy, maternity, and newborn care
• Mental health and substance use disorder services, including behavioral health treatment (includes counseling and psychotherapy)
• Prescription drugs
• Rehabilitative services and devices (used to help regain or recover mental and physical skills due to injuries, disabilities, or chronic conditions)
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

In addition to the essential health benefits, Wellpoint Silver plans include added enhanced benefits like $0 for commonly used prescription drugs and $0 virtual care visits. ^{1, 2}  

It's also important to review the specific details of the Silver plans offered by each of the insurers you're considering. For example, each plan and insurer may offer access to a different network of doctors and hospitals for care.

Understanding the Average Cost of a Silver Health Plan

The cost of a Silver health insurance plan varies depending on various factors, including your age, location, income, tobacco use, and family size. It’s also important to note that if you enroll in a Silver plan, you may qualify for cost-sharing reductions (CSRs) that can further reduce overall costs associated with your deductible, copays, coinsurance, and out-of-pocket maximum.

Before exploring how CSRs can help reduce the average cost of Silver health plans, it will help to better understand how those costs break down.

• Premium: Your monthly payment to your insurer to maintain coverage. Silver plan premiums are higher than those for Bronze plans, but lower than those for Gold or Platinum plans. A plan with a higher monthly premium typically means you’ll have a lower deductible, lower copays, and a lower out-of-pocket maximum.
• Deductible: The amount you must pay out-of-pocket for care before your insurer starts to pay. Silver plans usually have a moderate deductible, meaning it is higher than Bronze plans, but lower than Gold or Platinum plans. 
• Copays: A fixed amount you pay your care provider for each visit.
• Coinsurance: The percentage of costs you pay for care after meeting your plan’s deductible. The Silver plan’s coinsurance structure means that you pay 30% for the cost of care, and your insurer pays 70%.
• Out-of-pocket maximum: The most you pay for your healthcare expenses annually. Once you reach the maximum, your insurer covers 100% of eligible healthcare costs for the rest of the plan year. The out-of-pocket maximum varies depending on the specific plan and insurer. However, under the ACA, there are annual limits on the in-network, out-of-pocket maximums for plans offered through Covered California, including Silver plans. These limits are adjusted every year. The Centers for Medicare & Medicaid Services state that for the 2025 plan year, “the out-of-pocket limit for a health plan through Covered California cannot be more than $9,450 for an individual and $18,900 for a family.” ³

Cost-Sharing Reductions for Silver Plan Health Insurance

As mentioned above, Silver health insurance plans are unique among the four metal levels because they offer cost-sharing reductions (CSRs), which is financial help that lowers out-of-pocket costs for care. CSRs are one of two forms of health insurance subsidies provided under the Affordable Care Act to help eligible individuals and families afford health insurance.

The other type of subsidy is the advanced premium tax credit (APTC), which qualified consumers can use to reduce or eliminate their monthly plan premium. CSRs, on the other hand, can help consumers further reduce their out-of-pocket costs including their plan deductible, copays, and coinsurance, and out-of-pocket maximum. While APTCs are available across all metal levels, CSRs are only available through a Silver plan. It is also possible to qualify for both CSRs and advanced premium tax credits.

To qualify for CSRs, you must meet the following criteria:

• Enroll in a Silver metal level plan through Covered California.
• Meet the income requirements (250% or less than California’s federal poverty level). 
• Must not be eligible for Medi-Cal or Medicare. 

When you enroll in a Silver plan and qualify for CSRs, your insurer will automatically apply the savings to your plan. This means that your deductible, copays, coinsurance, and out-of-pocket maximum will be lower than they would be for someone who does not qualify for CSRs.

For example, if you have a Silver plan with a $3,000 deductible and you qualify for CSRs, your actual deductible may now be $1,500. This means that you would only have to pay $1,500 out-of-pocket before your insurer starts paying for covered medical expenses.

Comparing ACA Silver Health Plans with Bronze, Gold, and Platinum Levels

Choosing a Silver plan comes with its advantages, but it’s also important to review various factors, including affordability, coverage flexibility, and potential limitations to make an informed decision for you and your family. 

When considering any insurance plan, evaluate your and your family’s anticipated care needs, budget, and eligibility for financial help.

Silver plan health insurance is generally considered the most balanced metal level in terms of cost and coverage. Consider the below chart to see how you and your insurer will share the cost of care across each level: