What You Should Know About Platinum Plan Health Insurance

woman looking at health insurance paperwork
BSIP/UIG Universal Images Group/Getty Images

A platinum plan is a standardized type of health insurance that pays, on average, roughly 90% of members' health care expenses. The members pay the other 10% of their health care expenses in the form of copayments, coinsurance, and deductibles.

This standardization of health plans applies to policies in the individual and small group markets. Individual plans are those that people buy themselves, either through the health insurance exchange or directly from an insurer. Small group plans are those that are sold to small businesses (in most states, the term "small business" means it has up to 50 employees, although there are four states where employers with up to 100 employees are considered small businesses and buy health insurance in the small group market).

Platinum plans are widely available in the small group market. But in the individual market, they have proven to be much less popular than the other metal-level plans, due in large part to their high costs. As a result, insurers are much less likely to offer individual market plantinum plans, resulting in limited availability.

Background

To make it easy for you to compare the value you’re getting for the money you spend on health insurance premiums, the Affordable Care Act standardized actuarial value levels for health plans in the individual and small group market. These levels, or tiers, are bronze, silver, gold, and platinum. All of the health plans within a given level are expected to offer roughly the same overall value.

For platinum-tier plans, the value is 90% (with a de minimus range of +2/-4, meaning that a platinum plan will have an actuarial value in the range of 86% to 92%). Bronze, silver and gold plans offer values of roughly 60%, 70%, and 80% respectively.

What Actuarial Value Means in Regard to Health Insurance

Actuarial value, tells you what percentage of covered health care expenses a plan is expected to pay for its membership as a whole. This doesn’t mean that you, personally, will have exactly—or even close to—90% of your health care costs paid by your platinum plan. It’s an average value spread across a standard population. Depending on how you use your health insurance, you might have more or less than 90% of your expenses paid.

To illustrate that, consider a person with a platinum plan who has very little in the way of health care expenses during the year. Maybe she sees the doctor a few times and has some lab work done. Let's say her deductible is $500, and she has to pay it for the lab work. She also pays $20 for each of her four office visits. Her total costs might only come to a couple thousand dollars, and she's paid nearly $600, which is more than 10% of the cost. But what if she were diagnosed with cancer during the year, and incurred $500,000 in total costs? She would still pay her $500 deductible, and let's say her plan's maximum out-of-pocket is $1,500, which means she'd pay another $1,000 in coinsurance and copays. But at the end of the year, she's only paid $1,500 out of $500,000, which amounts to far less than 10% of the total costs.

Non-covered health care expenses don’t count when determining a health plan’s value. For example, if your platinum-tier health plan doesn’t provide coverage for over-the-counter medicines, the cost of those things isn’t included when calculating your plan’s value. Out-of-network costs are not included in the determination of a plan's actuarial value, and neither are benefits that don't fall under one of the essential health benefit categories (virtually all medically necessary care is considered an essential health benefit, however)

Premiums

You’ll have to pay monthly premiums to get the health plan coverage. Platinum plan premiums are more expensive than lower-value plans because platinum plans pay more money toward your health care bills.

Each time you use your health insurance, you’ll have to pay cost-sharing like deductibles, coinsurance, and copays. How each platinum plan makes enrollees pay their overall 10% share will vary. For example, one platinum plan might have a high $1,000 deductible paired with a low 5% coinsurance. A competing platinum plan might have a lower $400 deductible paired with a higher coinsurance and a $10 copay for prescriptions.

Pros

Choose a platinum health plan if the most important factor to you is low out-of-pocket expenses when you use your health insurance. If you expect to use your health insurance a lot, or you aren’t bothered by the higher monthly premiums of a platinum plan, a platinum health plan might be a good choice for you.

If you use your health insurance a lot, perhaps because you have an expensive chronic condition, take a careful look at the platinum plan’s out-of-pocket maximum. If you know in advance that your out-of-pocket expenses will exceed this out-of-pocket maximum, you might be able to save money by choosing a lower-tier plan with a similar out-of-pocket maximum but lower premiums. Your total yearly out-of-pocket expenses will be the same, but you’ll pay less for premiums

Cons

Don’t choose a platinum-tier health plan if you can’t afford high monthly premiums. If you lose your health insurance coverage because you couldn’t pay the premiums, you could find yourself in a tough spot.

If you’re eligible for cost-sharing subsidies because your income is below 250% of federal poverty level, you must choose a silver-tier plan in the exchange to get the subsidies. You won’t get the cost-sharing subsidies if you choose a health plan from any other tier, or if you shop outside of the exchange (premium subsidies are also only available in the exchange, but they can be used for plans at any metal level).

Cost-sharing subsidies lower your deductible, copays, and coinsurance so that you pay less when you use your health insurance. In effect, a cost-sharing subsidy increases the actuarial value of your health plan without raising the premium. It’s like getting a free upgrade on health insurance, and depending on your income, the upgrade can make the coverage as good as a platinum plan. You won’t get the free upgrade if you choose a platinum-tier plan.

Availability

Under the ACA, insurers that sell plans in the exchange are only required to offer coverage at the silver and gold levels. Platinum plans are much less popular than the other metal levels (as has been the case in prior years, platinum plans accounted for less than 1% of total exchange enrollment during the open enrollment period or 2019 coverage), and tend to have high costs for insurers, as the people likely to select them tend to be those with health conditions who anticipate significant utilization of healthcare during the year. 

Because of the low overall enrollment and high costs, insurers in most areas have stopped offering platinum plans in the individual market. That means you may not be able to purchase a platinum plan at all, although gold plans continue to be available.

If you get your coverage from a small employer (or if you're a small employer seeking coverage for your employees), you'll generally find platinum plans to be more widely available in the small group market than they are in the individual market. Insurers do tend to offer them, and it's up to the employer to decide which plan or plans will be the best fit for their team.

Was this page helpful?

Article Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial policy to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Centers for Medicare and Medicaid Services. Center for Consumer Information and Insurance Oversight. Market Rating Reforms. State Specific Rating Variations. Updated June 2, 2017.

  2. Department of Health and Human Services. Patient Protection and Affordable Care Act: Market Stabilization. April 2017.

  3. Centers for Medicare and Medicaid Services. 2019 Marketplace Open Enrollment Period Public Use Files. March 25, 2019.