Cost Sharing Question

[modhatter]

I understand that if you are below the 200% income threshold the ACA has set up that if you purchase a silver plan they will lower your Max OOP cast by a certain %. However just beneath that (I am referring the the ACA publication that Michael has linked to before), it talks about another cost sharing and shows a second chart, but does not go into any detail about it. It is table #7.

I can't copy the link (don.t know how to as it is a pdf file)

It gives different percentages in the table. Does anyone have an understanding of this and what it covers? Or someone tell me how to make a link to a PDF file and I'll post it if nec.

[rbmrtn]

I think that report used the original numbers and have changed in the final rule. The cost sharing subsidy starts @ 250%FPL and below for a silver plan. Here is another paper that discusses why the changes were made. http://www.cms.gov/CCIIO/Resources/F...r-bulletin.pdf

Basically it lowers your OOPM and increases the actuarial value of the plan. Here is a paper from Kaiser with some info http://kaiserfamilyfoundation.files....01/7962-02.pdf

Use the kaiser estimator to get some idea of what you would get. But since it involves changing the AV, each plan can arrive at the new AV with different combinations of deductibles/copay/coinsurance etc

[MRG]

Great question, so does anyone know how this is to be implemented i.e. will there be 4 silver plans from the same provider each with different copays, oop etc.

Or just one that magically figures out what your copay is? Folks at healthcare.gov can't tell me, thought I'd ask the experts.

MRG

[rbmrtn]

Quote:

Originally Posted by MRG Great question, so does anyone know how this is to be implemented i.e. will there be 4 silver plans from the same provider each with different copays, oop etc.

That's basically how it works. I only have one insurer playing in the exchange. For their silver plan, they have different plans at the different AVs and FPL for the cost sharing subsidy. They also list specific plans for indian/alaskan native subsidy.

[MRG]

Rbmrtn,

Thank you. I'll be back to the folks at healthcare.gov. We're under 200% FPL and don't see anything but the 'standard silver plans'.

Thanks again,

MRG

[MichaelB]

Another good link from rbmrtn. Thanks, I'll update the FAQ.

From the CMS paper, the exchange will designate one standard silver plan, and then re-do (mostly lower) the copays and deductible in order to get to the lower actuarial value, with three versions.

Quote:

In the third step, we intend to direct that a QHP issuer submit, along with each standard silver plan that it proposes to offer through the Exchange, three variations of that standard silver plan to match the statute’s three levels of cost-sharing reductions. The standard silver plan will have an out-of-pocket limit no greater than the maximum out-of-pocket limit required for all QHPs, and will have a 70 percent AV. The three silver plan variations would then be required to meet the out-of-pocket limits and AV requirements set forth below: a. For individuals with household incomes between 200 and 250 percent of the FPL, a silver plan variation with an AV of 73 percent and an out-of-pocket limit no greater than that set forth in the annual Federal notice; b. For individuals with household incomes between 150 and 200 percent of the FPL, a silver plan variation with an AV of 87 percent and an out-of-pocket limit no greater than that set forth in the annual Federal notice; and c. For individuals with household incomes between 100 and 150 percent of the FPL, a silver plan variation with an AV of 94 percent and an out-of-pocket limit no greater than that set forth in the annual Federal notice.

[rbmrtn]

Try your insurers site and see if they have anything listed, that is where I saw them listed. Since I was above the cutoff, I didn't pay any attention to it on the Fed exchange site.

[MRG]

Quote:

Originally Posted by rbmrtn Try your insurers site and see if they have anything listed, that is where I saw them listed. Since I was above the cutoff, I didn't pay any attention to it on the Fed exchange site.

Thanks I'll give that a try as well.

MRG

[modhatter]

So, does this mean that it is only the Max OOP figure changes ($6,260)? All the silver plans have Max OOP cost of $6,250. What changes is the deductibles. They range from $2,500 to $4,000 (4 different Silver Plans). The co-pays change by about $10 to $20 higher or lower per Dr. visit. Everything else pretty much stays the same.

[Rpharmer]

Quote:

Originally Posted by modhatter So, does this mean that it is only the Max OOP figure changes ($6,260)? All the silver plans have Max OOP cost of $6,250. What changes is the deductibles. They range from $2,500 to $4,000 (4 different Silver Plans). The co-pays change by about $10 to $20 higher or lower per Dr. visit. Everything else pretty much stays the same.

It depends on what bracket your MAGI falls in. In the lowest bracket, since AV is 94%, cost reductions are most noticeable -- at least in the plans I saw. Deductible, OOP max, copays, and coinsurance were all reduced. And there was variability among plans. For example, you could have a $250 deductible with a $500 OOP max. Or, you could choose a zero deductible, but with a $1000 OOP max.

In the higher, 200 to 250% bracket, not much tweaking had to be done, since the AV only had to be increased from 70% to 73%.

I think this is why some people were examining the possible advantages and risks of managing one's MAGI towards the lower levels. At the 100 to 150% level, you have to be aware of what your state has done or may still do about Medicaid expansion. In the worst case, you can have a MAGI that is too high for Medicaid (as your state defines it) but too low for the cost-sharing and premium subsidies. Or, you might qualify for Medicaid, when you would have preferred to buy a subsidized plan on the exchange.

Medicaid expansion (or possible "reform," as some are calling it here) is still being debated in Missouri. So, given that uncertainty, I'm targeting a MAGI of 140 to 149%. That way I can ignore the day-to-day drama in our State house. (There's enough to follow at the federal level as it is!)

[NoMoreJob]

Our state's exchange shows different deductibles and max OOPs and co-pays for silver plans depending upon the income entered when entering the site. Since we can shop as a visitor on our site you can see these numbers change as you change income.

When looking at the insurer's site I only find the 'standard' silver plan with the highest deductible, max OOP and copays which makes sense as they cannot directly subsidize.

When I dig into the policy details on the exchange I find that there is the master policy with sub-policies (these are my terms) numbered '-1', '-2' and '-3.' The sub policies are apparently created for the cost sharing levels - FPL 200-250, FPL 150-200 and FPL 100-150.

So as a practical matter there is the un-subsidized policy and three additional sub-policies that the exchange will pay additional for in order to 'buy-down' the policy's deductible, max OOP and copays for those it determines is eligible for cost sharing.

[MRG]

NoMoreJob,

Thank you for that detail. While I have the privilege of only being able to apply on the federal site, that gives me an idea of how it should work.

While I'm under 200% FPL I only see silver plans with 70% AV. and standard OOP etc. Makes me think that I have an issue with my account details. Or maybe the insurers in this area haven't uploaded plans.

The insurance company had some vague suggestions about multiple plans, no plans listed, numbers for OOP, deductibles, AV. .....

MRG

[modhatter]

Well, I was on the phone with a representative from one of the exchange insurance companies. It was the new Co-Op that was created. She said she could give me the numbers after I made out application with her. She said I sould just to see how numbers were effected in chosing one of the silver plans, which had a deductible of $4,500 and an out of pocket max of $6,350 (with high co-pays)

This is for my son and his income is at approx 153% FPL., when she finished his application, she said his deductible went down to $100 and his max out of pocket went down to $500. I told her that didn't seem right. That the maximum reduction in the max OOP for incomes at or less than 150% of the FPL was only 2/3rd, and above the 150% FPL it went to 1/2 the max OOP cost. She said the $500 is what the computer said. So I don't know what to make of it. I am about to go on line now to finish and I hope it will show me some numbers. So if it does I will let you know what it says. If it doesn't show me any numbers, I will get a surprise I may not be happy about as I was prepared to go to either the gold or silver plan, before she encouraged me to try the silver first. Stay tuned.