Understanding Gold Plan Health Insurance

Key Features of an ACA Gold Plan

Key features of a Gold plan include:

1. Premium: Gold plans generally have higher monthly premiums, the amount you pay each month for coverage. The higher premium reflects the increased percentage of costs covered by the insurer.
2. Deductible: Gold plans typically have a lower deductible compared to Bronze and Silver plans. Your deductible is the amount you must pay out-of-pocket before your insurer starts to make payments for covered medical services.
3. Cost sharing: Once you have met your plan’s deductible, you share the cost of healthcare with your insurer. The Gold plan’s cost-sharing structure means the consumer pays 20% for the cost of care, and the insurer pays 80%.
4. Out-of-Pocket Maximum: The out-of-pocket maximum a consumer would be responsible to pay for healthcare each year varies depending on the specific plan and insurer. However, under the ACA, there are annual limits on the in-network, out-of-pocket maximum for health plans, including Gold plans. These limits are adjusted annually. Healthcare.gov states that for the 2024 plan year, “the out-of-pocket limit for a health plan through Covered California cannot be more than $9,450 for an individual and $18,900 for a family.”¹

What Does a Gold Plan Cover?

All metal level plans, including Gold plans, must cover essential health benefits mandated by the ACA, including: 

• Ambulatory patient services (outpatient care received without being admitted to a hospital)
• Emergency services
• Hospitalization (surgery and overnight stays)
• Pregnancy, maternity, and newborn care
• Mental health and substance use disorder services, including behavioral health treatment (includes counseling and psychotherapy)
• Prescription drugs
• Rehabilitative services and devices (used to help regain or recover mental and physical skills due to injuries, disabilities, or chronic conditions) 
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care for children 

While all Covered California plans provide essential health benefits, you can also select plans through your insurer that include coverage like dental and vision insurance.

Review the details of the Gold plans offered in your state by the insurers you're considering. Plans and insurers may provide access to a different network of doctors and hospitals for care.

How Much Does a Gold Plan Cost?

The cost of a Gold plan can vary based on several factors, including your age, location, family size, and tobacco use.

While Gold plans are not eligible for cost-sharing reductions (CSRs), individuals who qualify for premium tax credits based on income can apply those subsidies to help reduce or eliminate their monthly premium.

It’s important to consider your healthcare needs and budget when reviewing a Gold health plan. Be sure to compare the costs and benefits of the different metal levels to make an informed decision for you and your family.

Benefits of a Gold Plan

Gold plans offer several benefits to individuals and families. Here are some key advantages associated with a Gold plan:

• Lower deductible
• Lower out-of-pocket costs for care
• Coverage for essential health benefits

Who Should Consider a Gold Plan?

A Gold health plan can be a suitable option for individuals and families who have specific or frequent healthcare needs and are willing to pay a higher monthly premium in exchange for lower out-of-pocket costs. Here are some situations where an individual or family may benefit from a Gold plan:

Those with chronic health conditions: If you or a family member have a chronic health condition that requires regular medical care, medication, or specialist visits, a Gold plan offers more comprehensive cost coverage. Lower copays, coinsurance, and deductible can make ongoing healthcare needs more affordable.

Those anticipating higher healthcare costs: If you expect to utilize healthcare services frequently due to planned procedures or anticipated treatments, a Gold plan can provide better financial protection. Lower out-of-pocket costs can help reduce the financial burden of healthcare expenses.

Families with dependents: Families with children or dependents may find Gold plans beneficial due to the broad coverage they offer. The lower out-of-pocket costs can make it easier to manage the healthcare needs of multiple family members.

Those requiring access to a broad provider network: Gold plans often come with larger networks of care providers, offering greater flexibility and access to a wide range of doctors, specialists, and hospitals. If having access to a broad network of doctors and hospitals is important to you, a Gold plan may be the right choice.

Those prioritizing predictability: Gold plans provide more predictable healthcare costs compared to lower-tier plans. With a lower deductible and your insurer covering 80% of the costs for care, it’s often easier to budget and plan for your health-related needs.

Consider your specific healthcare needs, budget, and preferences when selecting a health insurance plan. Evaluate the coverage, costs, and networks associated with Gold plans, and compare them with other available options to determine which plan best aligns with your requirements for health coverage.