Among the four new categories of health insurance plans created by the Affordable Care Act (ACA) is the Gold Plan. The Gold Plan offers the second lowest out-of-pockets of the new plan types. Only the Platinum Plan offers lower costs. The Gold Plan provides the same essential benefits as the other plan types. Essential benefits are the minimum services to be covered by an Affordable Care Act health insurance plan. However, individual plans do have the option of enhancing their benefits beyond the basic benefits required by the ACA.
Gold Plans are required to cover 80% of the medical costs with the remaining 20% paid by the plan enrollee. The 80% figure is based on the government’s expectation of healthcare usage. Depending on what services you use, this coverage may not exactly match 80% of medical costs. The 20% of healthcare costs paid by the enrollee would be in the form of out-of-pocket deductibles, copayments, and coinsurance fees. The monthly premium for the Gold Plan, however, is paid for in addition to the out-of-pocket costs mentioned earlier.
The Gold Plan is one of the two plan types that an insurance company must offer in order to participate in a health insurance exchange. A health insurance exchange is a state marketplace for health insurance plans meeting the ACA requirements.
Based on an average person’s expected use of healthcare services, Gold Plans have the insurance company pay 80% of covered healthcare expenses. The remaining 20% of expenses are paid by plan out of pocket. These out-of-pocket expenses include deductibles, copayments, and coinsurance. However, the plan’s monthly premium is not included as one of these out-of-pocket costs.
Below are the 2014 average cost-sharing expenses for gold plans sold on exchanges in 34 different states.
|Cost-Sharing Category||Average for a Gold Plan|
|Deductible for an individual enrollee||$1,277|
|Deductible for a family||$2,846|
|Annual cap on out-of-pocket costs for an individual||$4,081|
|Annual cap on out-of-pocket costs for a family||$8,649|
The specifics of deductibles, copayments, and other out-of-pocket costs will vary by Gold Plan, we do know that for a standard population the Gold Plan should be expected to cover 80% of healthcare expenses. To illustrate how costs could differ among Gold Plans, we’ve created a table of two hypothetical Gold Plans.
|Gold Plan Example A||Gold Plan Example B|
|Consumer Out-of-Pocket Costs||20% of costs||20% of costs|
One of the issues that the government intends to monitor is whether Gold and Platinum plans attract more sickly enrollees and drive up premiums. The ACA provides some tools to address this issue (e.g. reinsurance, risk adjustment, and risk pooling) but it is impossible to tell whether these tools will be sufficient if these plans do attract a disproportionate representation of high-cost enrollees.
No. If an insurer is selling on exchange, the insurer must offer at least a Silver Plan and a Gold Plan. The same rules do not apply to health plans sold off exchange.
Compare Obamacare Metal Health Plans in Your Area