ACA
B
The Affordable
Care Act:
eginning in 2014, the Affordable Care Act
(ACA) requires most Americans to obtain
health coverage. Low- and middle-income
individuals and families shopping for health
coverage through the state’s new marketplace,
Covered California, may be eligible for federal
subsidies to help them pay their premiums. Costsharing subsidies are also available to those who
qualify to lower their out-of-pocket expenses.
DCOST-SHARING SUBSIDIES RAISE THE VALUE
DAVERAGE HEALTH CARE COSTS BY PLAN
PREMIUM
Cost-Sharing Subsidies in CA
OF SILVER PLANS TO A GOLD OR PLATINUM LEVEL
All of the plans offered through Covered California have standardized benefits
and cover a uniform set of comprehensive services. The only difference
between the four tiers of coverage is the share of average health care costs
paid for by the plan in relation to the share paid for by consumers. Bronze and
silver plans have lower premiums but higher out-of-pocket costs while gold
and platinum plans have higher premiums but lower copays and deductibles.
Cost-sharing subsidies raise the value of a silver plan by lowering consumers’
out-of-pocket costs. In California, instead of paying 30% of average costs on a
silver plan, consumers receiving cost-sharing subsidies will only pay:
OUT-OF-POCKET
Platinum
5%
12%
26%
income up to 150% FPL*
($17,300 individual; $35,400 family)
90% VS. 10%
Gold
income up to 200% FPL
80% VS. 20%
Silver
($23,000 individual; $47,300 family)
70% VS. 30%
Bronze
*Federal Poverty Level
60% VS. 40%
PREMIUM ASSISTANCE
Lowers consumers’ monthly premiums; caps premiums
as a percentage of income
VS.
income up to 250% FPL
($29,000 individual; $59,000 family)
COST-SHARING SUBSIDIES
Lower consumers’ co-pays, coinsurance and deductibles;
cap annual out-of-pocket maximums based on income
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Estimated 2.6 million Californians eligible
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Estimated 1.6 million Californians eligible
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Annual household income up to 400% FPL*:
$46k (individual) $94k (family of four)
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Annual household income up to 250% FPL:
$29k (individual) $59k (family of four)
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Must purchase coverage through Covered California
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Must purchase coverage through Covered California
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Subsidy amount based on second-lowest-cost silver plan – can apply
subsidy to another plan but premium may be higher or lower
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Must select silver plan
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Subsidy credit automatically deducted from premium, consumer only
pays the remainder / Changes in income (raise, bonus, job loss) may
result in amount due or amount owed on tax returns
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Subsidy lowers consumer costs at point of service
(doctor’s office, hospital/lab fees); annual out-of-pocket
maximums also capped
DPREMIUMS & OUT-OF-POCKET COSTS FOR SUBSIDIZED SILVER PLANS
ANNUAL INCOME
(SINGLE COVERAGE)
$15k ~ $17k
$17k ~ $23k
$23k ~ $29k
$29k ~ $46k
$19-$57
$57-$121
$121-$193
$193-$364
None
$500
$1,500* Medical
$2,000*Medical
Primary Care Visit Copay
$3
$15
$40
$45
Generic Medication Copay
$3
$5
$19
$19
$25
$75*
$250*
$250*
Maximum Out-of-Pocket (Individual)
$2,250
$2,250
$5,200
$6,350
Maximum Out-of-Pocket (Family)
$4,500
$4,500
$10,400
$12,700
Consumer Portion of Monthly Premium
(Balance paid by federal subsidy)
Deductible
Emergency Room Copay
Copays are not subject to any deductible and count toward the annual out-of-pocket maximum. *Indicate benefits that are subject to deductibles.
FREE
Consumers at all income levels will have access to a wide range of
preventive services with no copays or deductibles.
For more information, please go to www.calhealthplans.org
Source: Covered California