Gold Plan – Affordable Care Act (Obamacare)
- Understanding the gold plan
- Gold plan out-of-pocket costs
- Gold plan premiums
- Gold plan enrollment numbers
- Average out-of-pocket costs for gold plans on the small business market
- Monitoring Enrollees
- Frequently asked questions
Understanding the Gold Plan
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-pocket costs of the new plan types. Only the Platinum Plan offers lower out-of-pocket costs for a standard enrollee population. 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 along with the silver plan 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.
Out-of-Pocket Costs for Gold Plan Enrollees
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 out of pocket by the policyholder. 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.
|Cost-Sharing Category||Average for a Gold Plan|
|Deductible for an individual enrollee||$1,277|
|Deductible for a family||$2,846|
|Preferred brand drugs||$39|
|Non-preferred brand drugs||$85|
|Specialty drugs||28% of specialty drug expense charged to patient as coinsurance fee (coinsurance fees used for specialty drugs in 52% of plans studied)|
|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|
Gold Plan Premiums
Gold plans have the second highest premium rates of the four new types of metal plans since they charge the second lowest out-of-pocket costs. However, there may be instances where the Gold Plan for one insurance company may charge a lower premium than the Bronze or Silver Plan of another insurance company, as well as instances where the Platinum Plan for one insurance company may charge a lower premium than the Gold Plan of another insurance company. Comparing plans is essential for anyone trying to minimize their healthcare expenses. HealthPocket’s health insurance comparison tool allows people to compare all the plans available in their area.
Below are the average monthly premiums found for 30, 40, 50, and 60-year-old individuals in Gold plans across 34 different states.
|Age 30||Age 40||Age 50||Age 60|
Gold Plan Enrollment Numbers
According to the Health and Human Services report for marketplace enrollment between October 1, 2013 and February 1, 2014, 12% of persons selecting a marketplace plan chose a Gold plan. For states running their own marketplaces, 10% of persons selecting a plan chose a Gold plan. For the federally-facilitated marketplace (FFM), 13% of persons selecting a plan chose a Gold plan. Specifically in the FFM 12% of females and 13% of males selecting a plan chose a Gold plan.
In terms of plan selection by age, 24% of persons selecting a plan in the FFM under the age of 18 chose a Gold plan. Moreover 10% of persons aged 18-25, 12% of persons aged 26-34, and 12% of persons aged 35- 44 selecting a plan in the FFM chose a Gold plan. Additionally 12% of persons aged 45-54, 13% of persons aged 55-64, and 9% of persons at least 65 years old selecting a plan in the FFM chose a Gold plan.
Average Out-of-Pocket Costs for Gold Plans on the Small Business Market
The Affordable Care Act required deductible caps on small business health plans. For individual enrollees the maximum deductible was $2,000 while for families the maximum deductible was $4,000. However the Department of Health and Human Services later indicated that small group health insurance plans used by businesses and other organizations were allowed to exceed the deductible caps, but only if necessary to maintain the correct percentage of enrollee out-of-pocket costs.
HealthPocket found the following average out-of-pocket costs for gold plans in the small business market.
|Cost-sharing category||Average for a Gold Plan|
|Medical deductible for individual enrollee||$1278|
|Medical deductible for family||$2872|
|Primary care visit||$23|
|Annual cap on out-of-pocket costs for an individual||$3,758|
|Annual cap on out-of-pocket costs for a family||$7,926|
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.
Gold Plan Frequently Asked Questions
How are Gold Plans different than other Obamacare health plans?
The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Gold Plan typically pays 80% of covered medical costs.
How much does a Gold Plan cost?
The monthly premium for a Gold Plan depends on the insurer from whom you purchase the plan, the number of people to be insured by the plan, your age, whether you smoke, and the region in which you live. You can use HealthPocket’s comparison tool to compare Gold Plan premiums in your area.
When Can I Enroll in a Gold Plan?
The first Open Enrollment period for the new Affordable Care Act health plans began October 1, 2013. Open enrollment this year ended March 31, 2014. The 2015 open enrollment period will be from November 15 to February 15. See our Open Enrollment article for more information.
What Is the Deductible Amount for a Gold Plan?
A deductible is the amount a consumer pays for covered medical services. HealthPocket found individual Gold plan medical deductibles were $1,277 on average in the individual and family market.
Are insurers selling metal plans off exchange required to offer a Gold Plan?
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.