For individuals and families whose income does not exceed 250% of the Federal Poverty Limit (FPL), there are special “cost-sharing reduction” versions of Obamacare plans. These cost-sharing reduction (CSR) health insurance plans reduce the out-of-pocket expenses enrollees pay toward deductibles, copayments, and coinsurance. Cost-sharing reductions do not apply to medical services not covered by the health plan. Services rendered by healthcare providers outside the CSR health plan’s network are typically not eligible for cost-sharing reductions.
Of the new Obamacare health insurance plans, only Silver Plans come in CSR versions. Bronze, Gold, and Platinum plans do not have cost-sharing reduction versions.
There are three different levels of Silver-CSR Plans. All are dependent on income eligibility. As the table below demonstrates, the lower the enrollee’s income, the higher the cost-sharing reductions the enrollee will receive.
|CSR Silver Plan for Enrollees w/ Incomes up to 150% FPL||CSR Silver Plan for Enrollees w/ Incomes from 151% FPL to 200% FPL||CSR Silver Plan for Enrollees w/ Incomes up from 201% FPL to 250% FPL||Standard Silver Plan|
|Portion of medical expenses typically paid by the health plan (i.e. actuarial value)||94%||87%||73%||70%|
|Portion of medical expenses paid for by typical enrollee||6%||13%||27%||30%|
|Limit on Annual Out-of- Pocket Costs||$2,250 individual / $4,500 family||$2,250 individual / $4,500 family||$5,200 individuals/ $10,400 family||$6,350 individual / $12,700 family|
Enrollment in a CSR health insurance plan must take place through a health insurance marketplace, otherwise known as a state exchange. Enrollees in a CSR plan do not have to track their out-of-pocket costs for a later reimbursement. The CSR administers the reduced level of cost-sharing for medical services.
While changes in income can result in an enrollee losing his or her eligibility to stay enrolled in a Silver-CSR Plan, the enrollee would not be responsible to reimburse the plan for previously received cost-sharing reductions.
Native Americans whose family income is less than 300% of the Federal Poverty Level shall have no cost-sharing payments. However, the qualified health plan must be purchased through a health insurance exchange.