Frequently Asked Questions for Small Group Employers and Their Brokers

What is metallic tiering?
The Patient Protection and Affordable Care Act (ACA) has changed many of the rules for health plans offered in the small group market. One of the most far-reaching changes is the requirement that all health plans in the small group market fit into one of four metallic tiers: Bronze, Silver, Gold or Platinum.
What do the metallic tiers represent?
Each metallic tier represents the actuarial value (AV) of the health plan. A Bronze Plan has an AV of 60; a Silver Plan has an AV of 70; a Gold Plan has an AV of 80; and a Platinum Plan has an AV of 90.
What is AV?
AV refers to the percentage of the medical expenses that a plan is designed to cover for a standard population. So, a Bronze Plan (AV of 60) will pay 60% of the cost of providing Essential Health Benefits (EHBs), a Silver Plan will pay 70% of those costs, a Gold Plan will pay 80%, and a Platinum Plan will pay 90%.
How did Health New England (HNE) determine which metallic tier its plans fit into?
The United States Department of Health and Human Services (HHS) developed a tool called the AV Calculator that all health plans in the United States used to determine the AV of their plans. HNE associates entered information about each plan and its cost-sharing into the AV Calculator. The AV Calculator then performed a series of calculations to determine the AV of the plan.
Does the metallic tier of a plan mean that the plan has the exact AV associated with that tier?
No. By regulation, HHS determined that each metallic tier would require an AV of +/- 2 percentage points from the AV associated with that tier. As an example, a Silver Plan must have an AV of between 68% and 72%.
I have a Silver Plan. Does that mean that I will always pay 30% of the cost of each of the EHBs I receive?
No. In determining the AV of a health plan, the calculation is based on the percentage of costs that the plan will pay for an entire standard population. The calculation is not based on any specific individual’s benefits.
Did HNE have to make changes to its plan offerings in the small group market in order to fit them into the metallic tiers?
Yes, there were some changes that had to be made. For most of HNE’s most popular plans, the changes affected the maximum out-of-pocket costs that a member will incur in any plan year. HNE did not eliminate any covered benefits in order to fit those plans into the metallic tiers.
My group received a notice that we will have to choose a new plan when we renew in 2014. Why is my current plan no longer being offered?
For some of HNE’s existing plans, the changes needed to fit the plan into a metallic tier made the plan look exactly like another of HNE’s plans. As a result, HNE decided to close those plans for ease of administration and other organizational efficiencies.
Will HNE help us to choose a new plan when the time comes to do so in 2014?
Yes. The representatives from the HNE Sales Department will work closely with our employer groups and their brokers to help them choose an HNE plan that best suits the groups’ needs.
Why is the number of prescription drug riders available now limited?
Prescription drugs are one of the categories of EHBs that are used to calculate a plan’s AV. As a result, the cost sharing applied to prescription drugs directly affects a plan’s AV. In order to have a plan fit into one of the metallic tiers, only certain cost sharing combinations could be used.
Why has the pediatric dental benefit in my plan changed so much?
Pediatric dental is one of the EHBs that all small group health plans must provide. The Division of Insurance (DOI) for the Commonwealth of Massachusetts selected the benchmark (or model) set of benefits that must be included in the pediatric dental coverage. HNE has expanded its prior pediatric dental benefit to comply with the benchmark plan chosen by the DOI.