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.
** On October 12, 2017, the administration announced that “Based on guidance from the Department of Justice, the Department of Health and Human Services has concluded that there is no appropriation for cost-sharing reduction payments to insurance companies under Obamacare. In light of this analysis, the Government cannot lawfully make the cost-sharing reduction payments.” There are currently discussions among politicians to authorize payments for the cost-sharing subsidies. HealthPocket will update this page as news develops.
There are three different levels of Silver-CSR Plans. All depend 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 with Incomes up to 150% FPL||CSR Silver Plan for Enrollees with Incomes from 151% FPL to 200% FPL||CSR Silver Plan for Enrollees with 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(in 2019)||$2,600 individual / $5,200 family||$2,600 individual / $5,200 family||$6,300 individual / $12,600 family||$7,900 individual / $15,800 family|
Enrollment in a CSR health insurance plan must take place through a health insurance marketplace, otherwise known as a public 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 have no cost-sharing payments. However, the qualified health plan must be purchased through a health insurance marketplace.
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