Gold plans have become relatively much cheaper for subsidized buyers on the ACA exchanges since Cost Sharing Reduction subsidy payments were terminated in the fall of 2017. Insurers have responded by placing the full cost of these subsidies onto only Silver plans. This has upped the benchmark premiums and made the net of subsidy prices for non-Silver plans much cheaper. Bronze plans have a target actuarial value of 60% and Gold plans have a target actuarial value of 80% while Silver has a target value of 70% and a silver loaded value in the mid-80s before risk adjustment does weird things to premiums. Hundreds of counties on Healthcare.gov have at least one Gold plan that has a premium below the silver benchmark.
Insurers have an amazing latitude in designing their plans. A Gold plan in 2020 can’t have an out of pocket limit above $8,150 and it has to have an actuarial value between 76% and 82%. Beyond that, insurers can do what they want basically whatever they want. I am curious as to what the smallest maximum out of pocket amount is for Gold plans?
I am mapping the lowest maximum out of pocket maximum for a Gold plan in the map above.
Very different alloys of Gold are available on Healthcare.gov.
There are low maximum out of pocket gold plans in North Jersey, Arkansas, central Atlantic coast Florida, Kansas, Wisconsin and a couple of other spots where the lowest out of pocket limit for a Gold plan is under $3,500. Structurally, most of the cost-sharing in these plans will be in the form of a deductible and there will be few exemptions from cost-sharing.
On the other hand, most of Texas and Oklahoma as well as big chunks of North Carolina and Virginia only offer Gold plans that have the maximum allowable out of pocket limit. These plans tend to have smaller deductibles and more services that are no cost-sharing.
Both of these choices can produce benefits. Individuals who know that they are going to have very big claims in a year will prefer, for a given actuarial value, that most if not all of their cost sharing will be in deductibles. A deductible only or a deductible heavy plan means that the individuals who have fairly light healthcare expenditures will be paying a large share of their health expenditure in cost-sharing. As the healthy pay relatively more, the sick pay relatively less.
Plans that are light on deductible with many exemptions in the cost sharing are better (at a given actuarial value) for individuals with light healthcare utilization and low claims. The odds are that their utilization will either be in exempted categories or could be merely copay or coinsurance instead of full deductible coverage. However, individuals who have an expensive year will be paying through the nose in cost sharing. In many circumstances, the difference between a Bronze plan and a Gold plan for someone with $30,000 or $50,000 in claims will be monthly premiums (Bronze will be cheaper) and cash flow where Bronze might be all deductible so all cost-sharing is up-front while the Gold plan will spread out the cost sharing over several months.
Not all that glitters is truly gold.