Affordable Care Act (Obamacare) and Out-of-Pocket Cost Subsidies

healthPlease consider this an addendum to my previous post on Early Retirement and The Affordable Care Act.

In addition to subsidies on health insurance premiums, the Affordable Car Act (ACA) provides subsidies on out-of-pocket costs to qualifying households when buying insurance from an exchange. The income requirements are more restrictive, but they further improve affordability for those with lower incomes by reducing their deductibles, copayments, coinsurance, and total out-of-pocket maximum limits.

Income eligibility requirements. In this case, the income cutoffs are 200% and 250% of the Federal Poverty Level (FPL). Modified adjusted gross income (MAGI) is used for income. Modified takes your AGI (Line 4 on a Form 1040EZ, Line 21 on a Form 1040A, or Line 37 on a Form 1040) and adds back in certain deductions like non-taxable Social Security income, foreign income, and tax-exempt interest.

For reference, here are the 2014 FPLs by household size listed with the 200% and 250% levels, as calculated by the Department of Health and Human Services (for 48 contiguous states, higher in Alaska and Hawaii).

2014 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA
Persons in
family/household
100% FPL 200% FPL 250% FPL
1 $11,670 $23,340 $29,175
2 $15,730 $31,460 $39,325
3 $19,790 $39,580 $49,475
4 $23,850 $47,700 $59,625
5 $27,910 $55,820 $69,775

 

Deductible, copayment and, coinsurance subsidies. These cost-sharing subsidies are only available if you start with buying a Silver plan. Now, the idea of a Silver plan is the insurer will pay 70% of covered health expenses across the entire population, leaving the insured to pay 30%. However, if your income is 150% FPL or less, you’ll only have to pay 6% of covered health expenses. If your income is between 150% and 200% FPL, you’ll only pay 13%. If your income is between 200% and 250% FPL, you’ll have to pay 27%.

Each plan will have a different way of implementing this overall requirement, usually by tweaking deductibles and copays. These may be referred to as Cost Sharing Reduction (CSR) plans.

Out-of-pocket maximum subsidies. The Affordable Care Act limits your maximum out-of-pockets expenses per year. Once you reach this limit, your insurance will pay for all of your covered healthcare expenses for the rest of the year. However, if you are under 200% or 250% FPL, these limits are even lower.

Modified Adjusted Gross Income 2014 maximum annual out-of-pocket cost, individual 2014 maximum annual out-of-pocket cost, family
100-200% FPL $2,250 $4,500
200-250% FPL $5,200 $10,400
> 250% FPL $6,350 $12,700

 

Note that you may read conflicting information elsewhere about reduced out-of-pocket limits being available to anyone at 400% FPL or less. That information is outdated (source). Those numbers were in the original law, but it was since revised to what is shown above.

Recap. These subsidies for out-of-pocket expenses provide another important income cutoff point to consider when purchasing health insurance independently from an employer plan. Your total healthcare expenses could vary significantly if your income is just $1 over the cutoff points of 200%, 250%, and 400% FPL.

More: Healthcare.gov (really wish this site was better), Kaiser Family Foundation, UC Berkeley Labor Center

Comments

  1. The other thing I would be thinking about in this area is trying to avoid being in the medicaid expansion pool. I don’t have first hand experience, but it seems like fewer doctors accept medicaid. In some respects its good that I have a few more years before my window opens so that some of this can sort itself out.

    I don’t think it should be on the backs of taxpayers, but, breaking the employer insurance model is a good thing.

  2. docblogger says:

    in our business school, for health mgt class last Spring we used this website someone found : https://www.healthsherpa.com/

    It allows you to check the Obamacare plans in your area without giving out any personal info (like on a real health exchange), and “play” with different household sizes and incomes to see what you can get and for how much- can possible be a planning tool if you’re contemplating retirement soon…

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