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Details on Out Of Pocket Max
Old 10-15-2013, 12:58 PM   #1
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Details on Out Of Pocket Max

When you are 200% of poverty level, you have an adjusted Maximum Out of Pocket Cost (in addition to reduced premium subsidy). From what I have picked up, in order for this to take place, it only applies if you purchase the 2nd lowest cost Silver Plan.

Is this correct? Does anyone have any reference to explain in detail how this aspect of lower Out Of Pocket criteria works?
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Old 10-15-2013, 01:02 PM   #2
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Originally Posted by modhatter View Post
When you are 200% of poverty level, you have an adjusted Maximum Out of Pocket Cost (in addition to reduced premium subsidy). From what I have picked up, in order for this to take place, it only applies if you purchase the 2nd lowest cost Silver Plan.

Is this correct? Does anyone have any reference to explain in detail how this aspect of lower Out Of Pocket criteria works?
See the section beginning on page 13 http://www.fas.org/sgp/crs/misc/R41137.pdf
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Old 10-15-2013, 03:36 PM   #3
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I have read the section beginning on page 13 many times and it may as we'll be written in Swahili. Don't understand a bit of it. Can someone explain in regular words?
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Old 10-15-2013, 04:38 PM   #4
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I have read the section beginning on page 13 many times and it may as we'll be written in Swahili. Don't understand a bit of it. Can someone explain in regular words?
Here is the language from the reg:
Quote:
In order to be eligible for cost-sharing subsidies, an individual must be enrolled in a silver plan, so that coverage will already have an AV of 70%.
Your tax credit subsidy is based on the 2nd least expensive Silver plan, but the cost-sharing subsidy only requires any Silver plan, which is what I am seeing on healthcare.gov. For the silver plans that I am looking at, the max OOP is $4233 (under 200% FPL) for family coverage.
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Old 10-15-2013, 05:22 PM   #5
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Originally Posted by modhatter View Post
When you are 200% of poverty level, you have an adjusted Maximum Out of Pocket Cost (in addition to reduced premium subsidy). From what I have picked up, in order for this to take place, it only applies if you purchase the 2nd lowest cost Silver Plan.

Is this correct? Does anyone have any reference to explain in detail how this aspect of lower Out Of Pocket criteria works?
Not quite, you have to be enrolled in a silver plan for the cost sharing subsidy and below 250% FPL. The 2nd lowest cost silver plan is what is used to base your premium subsidy on.

The Kaiser calculator will show what the reduce cost sharing subsidy is ( something less than 6350 ) for OOP max.

Here is a kaiser article on cost sharing In Addition To Premium Credits, Health Law Offers Some Consumers Help Paying Deductibles And Co-Pays - Kaiser Health News
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Old 10-15-2013, 06:50 PM   #6
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I was hoping to be able to choose a silver plan with the cost sharing. The only options for that when I'm browsing plans is for an HMO with very few providers in our area. The one for our current insurance carrier is not showing an option for a cost sharing plan even though it was listed on other sites. I'd like to get more info on providers but the links to the pages don't work.

The site workability still isn't perfect or close to it, but better than before.

Came back to correct this -

I found the silver plan with the cost sharing from our current carrier. It's much more expensive than I expected. Our 2nd lowest cost silver is $250/mo after subsidy and this one is $410/mo but with the lower deductible and max out of pocket.
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Old 10-15-2013, 07:02 PM   #7
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... For the silver plans that I am looking at, the max OOP is $4233 (under 200% FPL) for family coverage.
But if income (MAGI) is 201% FPL that OOP max jumps to $10,400. Another Cliff of Obamacare
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Old 10-15-2013, 07:43 PM   #8
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But if income (MAGI) is 201% FPL that OOP max jumps to $10,400. Another Cliff of Obamacare
That sucks and that's why I managed my MAGI to be under 200%. My income comes from dividends, capital gains, and Roth conversions. I have no pensions. I used Turbo tax last year to figure out how much I can Roth convert at the end of the year and made sure my income was under 200% and over 133% (no Medicaid expansion in FL). Based on my initial browsing, DW and I will save about $550 a month and have a much better plan.
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Old 10-15-2013, 10:23 PM   #9
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That sucks and that's why I managed my MAGI to be under 200%. My income comes from dividends, capital gains, and Roth conversions. I have no pensions. I used Turbo tax last year to figure out how much I can Roth convert at the end of the year and made sure my income was under 200% and over 133% (no Medicaid expansion in FL). Based on my initial browsing, DW and I will save about $550 a month and have a much better plan.
Tomz,

Here in Pa, which, like Fl, is not expanding Medicaid, my income can be as low as 100 % FPL ($11,490) and I can participate in the exchange (federal, not state) and get a subsidy. That's according to Healthcare.gov.

Not the same in FL ?
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Old 10-16-2013, 07:23 AM   #10
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Tomz,

Here in Pa, which, like Fl, is not expanding Medicaid, my income can be as low as 100 % FPL ($11,490) and I can participate in the exchange (federal, not state) and get a subsidy. That's according to Healthcare.gov.

Not the same in FL ?
You are correct. This was one of the screwed up things in the bill. If the Supreme Court wouldn't have made Medicaid expansion optional, this wouldn't have mattered.
Quote:
The Medicaid expansion was supposed to cover everyone below 138 percent of the federal poverty level, while the tax subsides were intended to cover everyone above that. A managerís amendment reworked much of the ACAís language, incorporating changes to nearly every section of the bill from the floor debate and accompanying backroom negotiations. Thatís the bill that was passed by the Senate on Dec. 24, 2009.
But the tax subsidy threshold was never revised from 100 to 138 percent after the Bridge Policy had been removed, as it logically should have been. That was an unintentional oversight, said sources who spoke with Governing. How did they miss it while the bill was being rewritten? It appears to be as simple as this: The Bridge Policy and the tax subsidy section of the Senate Finance bill are separated by more than 100 pages. When one section was changed, nobody remembered to check the other.
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Old 10-16-2013, 08:36 AM   #11
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But if income (MAGI) is 201% FPL that OOP max jumps to $10,400. Another Cliff of Obamacare
Between 201% - 300% of the FPL the max OOP for a family is $6350 according to the CRS brief.
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Old 10-16-2013, 10:31 AM   #12
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Between 201% - 300% of the FPL the max OOP for a family is $6350 according to the CRS brief.
Which is why we will be sure to stat at 19X% FPL next year.
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Old 10-17-2013, 01:52 PM   #13
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Between 201% - 300% of the FPL the max OOP for a family is $6350 according to the CRS brief.
So Kaiser article above got it wrong then?

"But people who qualify for cost-sharing subsidies will see their maximum out-of-pocket spending capped at $2,250 or $4,500 for single or family coverage, respectively, if their incomes are less than 200 percent of the poverty level, and $5,200 or $10,400 if their incomes are between 200 and 250 percent of poverty."

In Addition To Premium Credits, Health Law Offers Some Consumers Help Paying Deductibles And Co-Pays - Kaiser Health News
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