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actuarial value of 70 percent, on average, the covered individual is responsible for 30 percent
of the costs of all covered benefits. The covered individual could be responsible for a higher or
lower percentage of the total costs of covered services for the year, depending on the actual
health care needs and the terms of the insurance policy.
Applies to: Insurance carriers offering insurance coverage to small usinesses. Does not apply
to grandfathered plans.
Affordable
Minimum
Value
Coverage
Figure 2:
Affordable Minimum Value Coverage
Large Employers (with at least 50 employees)
Health plans cover
at least 60% of the
total allowed cost
of benefits using
the minimum value
definitions.
Employee
contribution does
not exceed 9.5%
of the employee’s
W-2 income.
Self-funded plans
and fully insured
plans not required
to cover Essential
Health Benefits
(EHB).
If EHB are included,
no dollar limits
on lifetime or
annual benefits
are allowed.
Figure 1:
Actuarial Value Standards
Small Employers ( ≤ 50 employees or ≤ 100 employees, depending on the state)
Bronze
60%
Silver
70%
Gold
80%
Platinum
90%
Note: The definition of actuarial value may vary by 2 percent.
Affordable, minimum value coverage means that health plans must generally cover at least 60
percent of the total allowed cost of benefits using the actuarial value definitions. Additionally, a
plan is considered affordable if the employee portion of the premium for self-only coverage is
less than 9.5 percent of the employee’s W-2 income. Large employers must meet affordable
minimum essential coverage requirements, or may be subject to a penalty.
Applies to: Large businesses (with 50 or more full-time employees or their equivalencies).
HIPAA excepted benefits are not subject to market reform changes of the ACA, and are
available to employers of all sizes, as well as individuals. These include: supplemental
indemnity coverage, hospital indemnity coverage, critical illness coverage, accident insurance,
vision and dental insurance, as well as wellness programs and value-added services.
Health Insurance
Portability and
Accountability
Act (HIPAA)
Excepted Benefits
