What are metal plans?
The Affordable Care Act (ACA) introduced “metal plans”—Bronze, Silver, Gold, and Platinum—to help consumers compare coverage options based on the level of cost-sharing they offer. Each plan covers a set percentage, meaning policyholders are responsible for paying a portion of all healthcare costs out-of-pocket. Understanding the cost balance and the annual maximum out-of-pocket limit (MOOP) for each metal tier helps policyholders predict how much healthcare spending they may pay each year.
It should be noted that MOOP expenses are unrelated to monthly premium costs for a health insurance policy. Premiums are required to keep a policy active and current, and the expense does not go toward the MOOP maximum amount.
What is the breakdown of maximum out-of-pocket limits by metal level?
1. Bronze Plans: 60% Insurance Coverage, 40% Out-of-Pocket
- Overview: Bronze plans cover about 60% of healthcare costs, with policyholders covering the remaining 40%. They offer the lowest monthly premiums but also have the highest deductibles and out-of-pocket expenses. The MOOP for Bronze plans is usually the highest among the metal tiers, meaning you may pay more out-of-pocket before reaching the MOOP cap.
- Ideal for: Individuals who are generally healthy and only need occasional care or who want low monthly premiums but are prepared to pay higher out-of-pocket costs.
- Out-of-Pocket Implications: While Bronze plans cap total out-of-pocket expenses at the MOOP limit, members may pay a substantial amount (typically thousands of dollars) before reaching it. Once the MOOP is met, the plan covers 100% of in-network healthcare costs.
2. Silver Plans: 70% Insurance Coverage, 30% Out-of-Pocket
- Overview: Silver plans cover about 70% of healthcare costs, with policyholders covering the remaining 30%. They have higher premiums than Bronze plans but lower out-of-pocket costs. The MOOP for Silver plans is moderate, and many individuals also qualify for cost-sharing reductions if their income falls within specific limits, further lowering their deductible and MOOP.
- Ideal for: Those with moderate healthcare needs who want a balance between premiums and out-of-pocket expenses.
- Out-of-Pocket Implications: Silver plans are a popular choice for individuals who may qualify for reduced MOOP limits through income-based subsidies, which lower monthly premium costs significantly for eligible enrollees.
3. Gold Plans: 80% Insurance Coverage, 20% Out-of-Pocket
- Overview: Gold plans cover about 80% of healthcare costs, with policyholders covering the remaining 20%. They have higher premiums but lower out-of-pocket expenses at the time of care and a lower MOOP limit than Bronze and Silver plans.
- Ideal for: People with frequent healthcare needs, such as ongoing prescriptions or treatment for chronic conditions, where the higher monthly plan premium is offset by reduced out-of-pocket costs.
- Out-of-Pocket Implications: Gold plan enrollees will pay a higher monthly premium to access lower copays and coinsurance. This is a strong choice for those who prefer predictable expenses and fewer surprise bills.
4. Platinum Plans: 90% Insurance Coverage, 10% Out-of-Pocket
- Overview: Platinum plans offer the highest level of coverage, paying about 90% of healthcare costs, with policyholders covering the remaining 10%. Monthly premiums are the highest, but these plans have the lowest MOOP, making them ideal for those who want the smallest out-of-pocket burden.
- Ideal for: Individuals with extensive healthcare needs, such as chronic conditions or frequent doctor visits, and those who prefer minimal out-of-pocket expenses.
- Out-of-Pocket Implications: Platinum plan members may not reach the MOOP as quickly as Bronze plan enrollees due to comprehensive coverage. However, if they do reach it, the plan covers all additional in-network costs.
How Metal Plan Names Help You Understand the Balance of Premiums, MOOP, and Out-of-Pocket Costs
The metal plan names—Bronze, Silver, Gold, and Platinum—reflect the share of healthcare costs each plan covers. Here’s what this means for consumers in terms of MOOP and healthcare cost balance:
- Higher Premiums, Lower Out-of-Pocket Expenses: As you move up the metal tiers, monthly premiums increase while medical bill out-of-pocket costs and MOOP limits generally decrease.
- Risk Assessment: Bronze and Silver plans, with higher MOOP limits, may suit younger, healthier individuals or those with lower anticipated medical needs. Meanwhile, Gold and Platinum, with lower MOOP limits, appeal to people with greater health needs who prefer to reduce their out-of-pocket exposure. The metal plan you purchase may also be impacted by the availability of other supplemental coverage in your area.
The Maximum Out-of-Pocket Limit (MOOP) in Context
Every metal tier has an ACA-regulated annual MOOP cap that limits the amount policyholders pay for essential in-network services. In 2025, for example, the MOOP is capped at $9,200 for an individual and $18,400 for a family across all ACA plans. This cap applies only to covered services; non-covered or out-of-network care costs do not count toward the MOOP.
Summary: Metal Plans Can Help You Choose Based on MOOP and Expected Costs
Metal plans provide a flexible range of options to fit various needs, from low-premium, high-MOOP Bronze plans to high-premium, low-MOOP Platinum plans. Those with minimal healthcare needs may lean toward a Bronze plan with lower monthly costs, while those with frequent care needs benefit from Gold or Platinum plans, where more of their costs are absorbed through premiums and capped at a lower MOOP.
Ultimately, understanding each plan’s MOOP cap in relation to premiums and out-of-pocket costs empowers consumers to make informed choices that match both their financial and healthcare needs.
