cost sharing

Open Enrollment Tips, Part 1: An Educated Consumer Is Our Best Customer

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Some of you--of a certain age--may remember the Sy Syms commercial, with the tagline, "An Educated Consumer is Our Best Customer." Well, what's true for buying clothes is even more true (100 times more important, probably!) for choosing health insurance. 

So here are a few things to know, if you are shopping for health insurance. 

1. If you are very low income, you may be eligible for Medicaid. If you think you are eligible for Medicaid, do the MIBridges Medicaid application. Don't assume the Marketplace will send you there correctly--it is supposed to, but the two systems are not well-calibrated. (We help with those applications, too.)

2. If you had a plan last year, don't let it auto-renew. Spend the hour it requires to assess everything again. Provide revised income estimates, check your dependents, update your address. Most importantly, the plans have changed. In some cases, they have changed A LOT. 

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Make sure you are aware of which doctors or health systems are in-network or out of network for any plan that you choose. These networks can also change between plan years. 

Because costs are calibrated for tax credits based on the second-lowest cost silver plan, when the costs for that plan change (and this year they changed a lot!), the tax credits change a lot too. But if you were eligible for subsidies before, and your income is similar, you will pay the same or less--but you may need or want to change plans.

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3. If your income is a bit higher than Medicaid, but still under 200% of the poverty level ($24,120 for a single person, $49,200 for a family of 4) you will probably find the best deals with the Silver plans. (Probably. You may still want to compare the gold and bronze plans as well.)

4. If your income is between 200% and 400% of the poverty level ($24,120-$48,240 for a single person, $49,200-$98,400 for a family of 4), it is highly likely that you will find the gold and bronze plans more appealing. Gold plans, on average, will cover 80% of your medical costs and Bronze plans, on average, will cover 60% of your medical costs. 

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Explainer: The Trump administration made some last-minute changes removing cost-sharing subsidies, which are only applied to silver plans. Because of this, the cost of silver plans went up more than the cost of gold or bronze plans. But because tax credits are calculated based on silver plans, your tax credit will likely go further on the bronze or gold plans. If you want the details, read this

5. If your income is over 400% of the poverty level ($48,240 for a single person, $98,400 for a family of 4), you will not qualify for tax credits. But you might find better deals off of the Marketplace. Work with an in-person or online insurance broker, and make sure you are choosing from ACA-compliant plans. These should be marked as Bronze, Silver, Gold or Platinum. If they are ACA-compliant, they will have the same essential benefits, but the cost may be less expensive.

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Washtenaw Health Plan staff will answer your questions and help you figure it out.  It's complicated.  Different people in a family may get different coverage. Parents may qualify for the Marketplace, kids may qualify for Medicaid or MIChild.  An older couple might have Medicare, Medicaid and/or Marketplace.  No situation is too complex, no question should go unanswered.  We'll help sort it out.  

Call 734-544-3030 or walk-in to 555 Towner St. Ypsilanti from 9 am to 4 pm Monday through Friday.  

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What Are Cost Sharing Reductions And Why Do They Matter?

Under the Affordable Care Act, there are subsidies for insurance. Both parts of the subsidies--the Advance Premium Tax Credits (APTCs) and the Cost Sharing Reductions (CSRs)--are part of the law. To cover those costs, the government pays the insurance companies that participate in the Marketplace for these subsidies. President Trump has proposed just not paying the CSRs, BUT--as Vox explains--

If CSR payments were not paid, insurers would still be required to reduce cost sharing, but they would now have to do it without the government’s help. They would have to raise premiums dramatically to make up the lost revenue. The irony is that if plans do raise premiums, the federal government would be on the hook for much of those costs. The government absorbs premium increases through the tax credits that help people afford coverage. The law is designed to keep premiums manageable for people, so it falls on the government to cover any excess increases.

Some Background: Two Parts Make The Subsidies Work

There are two parts to the subsidies that people who get health insurance through the exchanges may receive.

Part 1--which most people are familiar with--is called the Advance Premium Tax Credits (APTCs). They assist people who are up to 400% of the poverty level ($98,400 for a family of 4), to help afford monthly premiums.

Part 2--which most people are not familiar with--are Cost-Sharing Reductions (CSRs). These support families whose income is between 138% of the poverty level (Medicaid cut-off) and 250% of the poverty level ($61,500 for a family of 4), by reducing what they would pay for co-pays, co-insurance, and deductibles.

 

For Consumers, Cost-Sharing Seems Like Magic

For households that qualify, cost-sharing applies to silver plans (only), and transforms them into something better--often much, much better. 

The truth is, if not for the CSRs, low-income families might be able to afford the premiums, but visits to the doctor could be cost-prohibitive, and high deductibles and maximum out-of-pocket costs would mean that getting sick could still turn a family's life upside down.

More than half of the people in the U.S. who got health care on an exchange got cost-sharing reductions (7 million out of 12 million)! 

Actuarial Value

Actuarial value is an estimate of the percentage of costs that--on average--a plan will cover. (For any one family, this might be a bit higher or lower.) Under the ACA, a household with income below 150% of the poverty level can get a silver plan that covers 94% of their costs; a household with income between 151%-200% of the poverty level can get a silver plan that covers 87% of their costs; and a household with income  between 201%-250% can get a silver plan that covers 73% of their costs.

Summary

Basically, taking away Cost Sharing does not save the government any money and will contribute to Marketplace insurers opting out of the Marketplace.  The only people who will be hurt are people who are low income but not low enough for Medicaid. Republicans were eager to eliminate cost-sharing when the repercussions would be seen as Democrat's fault but now that the the White House and Congress are Republican, we hope they do not want this cut to be seen as their responsibility. The ACA's solvency relies on Cost Sharing Reductions and Advanced Premium Tax Credits. #savetheACA

-Ruth Kraut 

Have a question?  Type it in the comments section and we will get back to you.

More Information:

Republicans are begging Trump not to sabotage Obamacare - Vox

What are cost-sharing reductions, and what happens if Trump ends them? - Michigan Radio

ACA Cost-Sharing Subsidies: How One Decision Could Disrupt Obamacare Marketplaces - Kaiser Family Foundation

Larry Levitt Tweets 

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How Does Your Income Affect the Cost of Your Marketplace Plan?

If you're looking for health insurance on the Marketplace, there are three things you should keep in mind when setting a budget for your plan:

  1. Your monthly premium: the amount you have to pay each month to keep your plan active.
  2. Your deductible: the amount you have to pay by yourself for your health care before insurance will help cover your costs.
  3. Your out-of-pocket maximum: the highest amount you will pay all year. Once you pay this amount your insurance covers all the costs for the rest of the year.

Thankfully there’s assistance to help pay for all three for those who need it!

Premium Tax Credits Help Lower the cost of Your Monthly Premium

You might have heard of premium tax credits, but how does the government decide how much you have to pay and how much help you get? It all comes down to income. The Affordable Care Act has set guidelines for the maximum percentage of your income you’ll have to put towards your monthly premium. Those percentages are called premium caps. That cap is used to calculate the dollar amount you will have to pay and then you get a premium tax credit to cover the rest of the cost of your plan. The more you make, the higher your cap, and the less you make the lower your cap. So the lower your income the more you can get in premium tax credits. The table below shows the premium caps based on level of income.

Cost-Sharing Subsidies Help Lower Your Deductible and Out-of-Pocket Maximum

If you make less than 250% of the poverty level and choose a silver plan, then you can get extra help with your out-of-pocket expenses. This extra help is a cost-sharing subsidy. The subsidy works by lowering your out-of-pocket maximum and your deductible, and raising the percentage of costs covered by your insurance. Normally a silver plan covers 70% of the cost and you have to pay the other 30%. But with cost-sharing subsidies your insurance might cover 73%, 87%, or even 94% of your expenses – meaning you have to pay less out of pocket. The amount of help you get is based on your income and, again, the lower your income the more help you receive.

Check out this example to see how premium tax credits and cost-sharing subsidies can work together to make your health care affordable!

If You Make More, You Pay More; If You Make Less, You Pay Less

If your income does not qualify you for significant cost-sharing subsidies on the silver plans, you may find that a bronze, gold, or platinum plan is better for you. 

To get an idea of what assistance you might be eligible for, visit the Marketplace at www.healthcare.gov/see-plans.

--K. Okarski

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