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Lowering Your Costs For Marketplace Health Insurance Coverage

Jean Folger
Supporters of the Affordable Care Act, widely referred to as "Obamacare", gather outside the Jackson-Hinds Comprehensive Health Center in Jackson, Mississippi October 4, 2013. Mississippi is one of at least 20 states that has decided not to expand Medicaid under the Affordable Care Act. REUTERS/Jonathan Bachman (UNITED STATES - Tags: HEALTH POLITICS BUSINESS)

In early 2010, President Obama signed into law the Affordable Care Act, designed to expand access to healthcare coverage to millions of Americans. While the rate you pay for health insurance typically goes up each year due to rising medical costs, rates are expected to increase even more because of changes under the healthcare reform.

Some of the changes include new taxes and fees, and increased benefits known as Essential Health Benefits. These benefits are the minimum requirements for all health plans – whether you buy health insurance directly from an insurance company, with the help of an agent or broker, or through the new Health Insurance Marketplace. While certain plans will offer additional coverage, none can offer less. Essential Health Benefits include:

  • Addiction treatment
  • Ambulatory patient services
  • Care for newborns and children
  • Chronic disease treatment (such as diabetes and asthma)
  • Emergency services
  • Hospitalization
  • Laboratory services
  • Maternity care
  • Mental health services
  • Occupational and physical therapy
  • Prescription medications
  • Preventive and wellness services (such as vaccines and cancer screenings)
  • Speech-language therapy

Despite rising costs, many individuals and families will qualify for two new federal subsidies that will help lower health insurance costs: Cost-Sharing Reductions and Advanced Premium Tax Credits. The only way to take advantage of these subsidies is to purchase a plan through the Marketplace (check out www.healthcare.gov for more information). In addition, many states are expanding the Medicaid program and more people than ever will qualify for free or low-cost care. Here, we take a look at how you may be able to lower your costs for health insurance coverage in 2014.

The New Health Insurance Marketplace

In order to qualify for Cost-Sharing Reductions and Advanced Premium Tax Credits, you must purchase coverage through the new Health Insurance Marketplace. The Marketplace, or “Exchange,” was established as part of the Affordable Care Act as a new way to compare and purchase health coverage. Each state has its own Marketplace where private health insurance companies – including big names such as Blue Cross, Cigna, Humana and Kaiser – will offer a variety of healthcare plans starting October 1. All plans are separated into four “metallic” levels: Bronze, Silver, Gold and Platinum. The level determines the average percentage that the plan will pay towards your healthcare services:

Plan Level What the Plan Pays
Bronze 60%
Silver 70%
Gold 80%
Platinum 90%

Bronze plans, for example, provide the lowest level of coverage (60%) but this level also have the lowest premiums – the amount that you pay each month to buy the plan. As the plan level increases (from Bronze > Silver > Gold > Platinum) so does the coverage – and your monthly premium.

Even within the same metallic level – Silver, for example – you will still have a number of coverage options from which to choose. These options affect both your premiums and out-of-pocket costs for deductibles, copayments and coinsurance. Compare these two hypothetical plans for a 35-year-old non-smoker:

Silver Plan “A” Silver Plan “B”
Premium (annual) $5,836 $3,408
Deductible $500 $3,500
Copayment $25 $40
Coinsurance 20% after deductible 30% after deductible

As the table shows, Plan A will cost you more up front for your monthly deductible, but your out-of-pocket expenses will be much lower. Conversely, Plan B will cost less each month, but you will pay more for health care expenses because of the higher deductible, copayment and coinsurance amounts.

Cost-Sharing Reductions

Depending on your modified gross adjusted income (MAGI) and family size, you may be eligible for subsidies to reduce your healthcare costs. The Cost-Sharing Reduction is a discount available on Silver plans only; it can help lower your out-of-pocket costs for:

  • Deductibles – the amount you owe for covered services before insurance kicks in;
  • Copayments – a fixed amount you pay for a covered healthcare service; and
  • Coinsurance – your share of the costs of a covered healthcare service.

As an example, say you visit the doctor and are charged $100. With your particular Silver plan, you normally have a co-pay of $25. Because you qualify for Cost-Sharing Reductions and you chose a Silver plan through the Marketplace, however, your co-pay may be as low as $5. Similarly, if your plan has a $3,500 deductible, it may be lowered to $500 with Cost-Sharing Reductions. Essentially, you pay for a Silver plan, but receive the increased coverage of a higher metallic level plan, which reduces your out-of-pocket expenses.

Cost-Sharing Reductions are available only to people:

  • Who are ineligible for public coverage [e.g. Medicaid, Children’s Health Insurance Program (CHIP)]
  • Who are unable to get qualified health insurance through an employer, and
  • Whose incomes fall between 100 and 250% of the Federal Poverty Level (FPL):
Family Size 100% FPL 250% FPL
1 $11,490 $28,725
2 $15,510 $38,775
3 $19,530 $48,825
4 $23,550 $58,875
5 $27,570 $68,925
6 $31,590 $78,975
7 $35,610 $89,025
8 $39,630 $99,075

Tip: In order to receive Cost-Sharing Reductions, you must enroll in a Silver plan through the Health Insurance Marketplace and apply for the subsidy. And it’s important to note, the cost-sharing subsidies only apply to in-network expenses, so you have to be mindful about where you receive healthcare.

Advanced Premium Tax Credits

Many people are expected to qualify for Advanced Premium Tax Credits, a type of subsidy that lowers monthly premiums. Like the Cost-Sharing Reductions, you must be ineligible for public coverage and unable to get qualified health insurance through an employer in order to qualify for Advanced Premium Tax Credits. While you can choose any metallic level plan in the Marketplace, your income must fall between 100 and 400% of the Federal Poverty Level:

Family Size 100% FPL 400% FPL
1 $11,490 $45,960
2 $15,510 $62,040
3 $19,530 $78,120
4 $23,550 $94,200
5 $27,570 $110,280
6 $31,590 $126,360
7 $35,610 $142,440
8 $39,630 $158,520

Advanced Premium Tax Credits are sent directly from the government to your health insurer to reduce your monthly premium. If you qualify, you can decide how much advance credit payments will be applied to your premium each month – up to a maximum amount. You will receive a refundable credit when you file your federal income tax return if the amount of advance credit payments is less than the tax credit you should have received. Conversely, you will have to repay any excess advance payments with your tax return if your advance payments for the year are more than the amount of your credit.

The Kaiser Family Foundation calculator is an online tool that shows the subsidy you might receive based on your expected 2014 income, the number of adults and children enrolling in coverage, age, family size and tobacco use (many states impose a premium surcharge on smokers). Using the calculator, a family of four – two non-smoking adults (both age 25) and two children – with a family income of $50,000 could receive a tax credit subsidy up to 66% of their overall premium. In this example, an unsubsidized annual health insurance premium might be $9,893, of which $3,365 would be paid by the family and $6,528 (66%) would be covered through Advanced Premium Tax Credits.

Tip: In order to receive this subsidy, you must apply for Advanced premium Tax Credits on the Health Insurance Marketplace. This subsidy is not automatic. If you qualify, you can take advantage of both Cost-Sharing Reductions and Advanced Premium Tax Credits to reduce both your monthly premium and out-of-pocket costs.

Catastrophic Coverage

A catastrophic health plan doesn’t cover any benefits other than three primary care visits per year before the deductible for the plan is met (like other plans, catastrophic plans also cover preventive services at no cost to you). The premium you pay each month should be considerably lower than for other plans, but the out-of-pocket costs (deductibles, copayments and coinsurance) are generally much higher. You may be eligible for a catastrophic plan if you are less than 30 years old or if you qualify for a “hardship exemption,” because you are considered unable to afford health coverage (this is determined during the application process and is based on your family size and income).

When you fill out an application on the Health Insurance Marketplace, you will see catastrophic plans listed among your plan options only if you qualify for them. If you do qualify for and choose a catastrophic plan, you will not be eligible for either Cost-Sharing Reductions or Advanced Premium Tax Credits.


Depending on your income and family size, you may qualify for Medicaid, a program that provides health coverage for eligible:

  • Low-income individuals, families and children
  • Pregnant women
  • The elderly
  • People with disabilities

Each state has its own rules about who qualifies for Medicaid. Under the Affordable Care Act, Medicaid eligibility is expanding in many states, and an increased number of people will qualify for benefits starting in 2014. If you are eligible, you can get free or low-cost coverage and you won’t need to buy a Marketplace plan. Many states also have a separate program – the Children’s Health Insurance Program (CHIP) – which provides health insurance for uninsured children in low-income families that do not qualify for Medicaid but who cannot afford private coverage. Starting October 1, you can fill out an application on the Health Insurance Marketplace to find out if you are eligible for Medicaid or CHIP benefits. You can also visit your state’s Medicaid website to apply and find out if you qualify.

Tip: Even if you don’t qualify for Medicaid now, you might in 2014. Apply on your state’s Medicaid website or see the Health Insurance Marketplace at www.healthcare.gov to find out if you qualify.

The Bottom Line

Starting in 2014, if you can afford health insurance (based on your family size, income and the cost of plans available to you) but don’t have coverage, you may have to pay a fee of 1% of your annual income or $95 per person, whichever is higher. The fee increases to 2.5% of your annual income or $695 per person in 2016. While this seems like a relatively small amount to pay, it is important to consider that you will also be responsible for 100% of your healthcare costs. Many people will find they are eligible for money saving subsidies if they purchase coverage through the Health Insurance Marketplace, making health insurance significantly more affordable than expected.

Many individuals and families will be able to compare and purchase health coverage through the new Health Insurance Marketplace, starting October 1. After you fill out an application, you can see if you qualify for Medicaid, CHIP, Cost-Sharing Reductions and/or Advanced Premium Tax Credits. You will also find out if you are eligible for a catastrophic plan that charges lower premiums but higher out-of-pocket costs.

In addition to Essential Health Benefits, all Marketplace and many other health plans must cover a set of preventive services such as shots and screening tests at no cost to you, meaning you will not have to pay a copayment or coinsurance. This is true even if you haven’t met your annual deductible. Preventive services include (but are not limited to):

  • Alcohol misuse screening and counseling
  • Blood pressure screening
  • Cholesterol screening
  • Colorectal cancer screening
  • Depression screening
  • Diabetes (Type 2) screening
  • Diet counseling
  • HIV screening
  • Immunization vaccines
  • Obesity screening

To find additional information regarding the new Health Insurance Marketplace and subsidies, as well as state-specific information and how to apply in your state:

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