Gold Plan Inside the Health Insurance Exchange

Accounting conceptGold plans inside the Health Insurance Exchange tend to be more expensive but come with better coverage than the other tiers. Here is what a Gold Plan inside of the exchange could look like from a benefit standpoint.

  • Deductible levels: $500- $1,500 and then double for family.
  • Co-insurance levels: anywhere from 20%- 10%.
  • Out of pocket maximums are $6,350 single and $12,700 for family.
  • Office visit copay: co-payments range from $15 all the way up to $50.
  • Specialist co-pays are from $25 all the way up to deductible and co-insurance.These prices range depending on what type of plan you pick.
  • Prescription drug co-pays: generic co-pays from applying towards the deductible to $15, preferred brand ranges from $25-$75, and specialty co-pays from applying towards the deductible to $75. Some of the plans designs are running a specific deductible for RX, so you may have to pay $250 before the co-pay kicks in. Of the four plans designs, we are starting to see the phrase “Requires Prior Authorization” popping up. It looks like you may have to get prior authorization to fill some prescriptions.
  • Urgent care co-pay: a $100 co-pay looks like the standard with most of the plans.
  • Emergency room: co-payment of $250-$500 and then applying towards the deductible.
  • Outpatient services: deductible and co-insurance.
  • Inpatient hospital services: deductible and co-insurance.
  • Mental health and substance abuse: deductible and co-insurance.
  • Maternity and newborn care: prenatal and postnatal care with a $25 co-pay, delivery going towards deductible and co-insurance.

This is just a snapshot of what the Gold Health Plan benefit may look like. Of the four plans that have been submitted to the Indiana Department of Insurance, we are seeing big differences in plan designs. One should really take the time to work with a Broker that is authorized to sell these plans; the difference in plans design could have a huge impact on what you pay out of pocket. The other issue is irritability…if you have to get prior authorization to fill a prescription, is that really the plan you want to go with?