CPPP
Slides
for
Texas
CHIP
Coalition
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8/23/2013: Deeper Dive into New Marketplace
Anne Dunkelberg, Associate Director – dunkelberg@cppp.org
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CPPP.org
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2014: ACA Provides Public Support Fitted to Income
>$89,400 for a
family of four;
>400% of FPL
Family Income
$67,100-$89,400;
300-400% of
FPL
$44,700-$67,100;
200-300% of
FPL
 Job-based coverage, or
 Full-cost coverage in the exchange
 Job-based coverage, or
 Subsidized exchange coverage: premiums capped
at 9.5% of income
 Job-based coverage, or
 Subsidized exchange coverage: premiums capped
at 6.3 – 9.5% of income
CHIP
• Job-based coverage, or
• Subsidized exchange coverage:
premiums capped at 3% - 6.3%
of income
Medicaid
???Medicaid???
$29,700-$44,700;
133-200% of
FPL
<$29,700 for a
family of four;
< 133% FPL
Children
Family income based on 2011 federal poverty income levels for a family of four
Adults
(non-disabled adults,
not eligible for Medicare)
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Coverage Level Options in the Exchange
All plans will cover
essential benefits:
hospital, ER, mental
health, maternity, Rx,
preventive care, chronic
disease management
and more.
% enrollee
cost share
% covered by plan
90%
Platinum
Gold
80%
70%
Silver
4 standard levels, (plus a
5th catastrophic plan for
people under age 30 or if
no other coverage is
affordable)
Bronze
0%
20%
60%
40%
60%
10%
20%
30%
40%
80%
100%
Options vary by % of covered benefits paid by the plan on average
vs % covered through out-of-pocket enrollee cost sharing
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Center on Budget and Policy Priorities
What Kind of Coverage Can People Buy?
Plan Tier
Actuarial Value
Platinum
90%
Gold
80%
Silver
70%
Benchmark
Bronze
60%
Lower premiums, higher enrollee
cost-sharing
Higher premiums, lower
enrollee cost-sharing
cbpp.org
The Affordability Puzzle
1) Premium Credits
2) Help with Health Care Costs
 Preventive Services
 Out-of-Pocket Caps
 Cost-Sharing Subsidies
Out-of-Pocket Caps: Key Points
 All new health insurance plans will
have OOP caps beginning in 2014
 Caps apply only to covered services
% of FPL
100-200% 200-300% 300-400% 400%+
Annual Out- individual
$2,017
$3,025
$4,033
$6,050
of-pocket
family
$4,033
$6,050
$8,067 $12,100
Maximum
Premium Credits: Eligibility
Primary Group: Individuals and families
between 133* and 400 percent of
poverty
Two additional groups:
1) Legally present people below 133%* of poverty
who are not Medicaid eligible
2) People who would have to spend more than 9.5%
of income to participate in employer plan or
whose employer plan has less coverage than the
“bronze” exchange plan
Premium Credits: Key Points




Sliding scale relative to income (premiums
capped at 2-9.5% of income)
Must be used to purchase coverage in
exchange
Value of credit linked to second lowest-cost
silver level plan (the “silver reference plan”)
People can choose any level of plan (e.g.
bronze, silver, etc), but MUST select a silver
plan to get cost-sharing subsidy
Center on Budget and Policy Priorities
How Is the Amount of the Tax Credit Determined?
Credit amount
=
Cost of benchmark plan
–
Expected premium contribution
Credit amount affected by:
• Individual or family’s expected contribution
based on their income
• Premium cost for benchmark plan
cbpp.org
Center on Budget and Policy Priorities
John:
Age: 24
Plan Cost: $5,000
Example 1: 200% FPL
Example 2: 300% FPL
Income: $22,980
Income: $34,470
Expected Contribution:
• Share of income: 6.3%
• Amount: $1,448
Expected Contribution:
• Share of income: 9.5%
• Amount: $3,275
Premium Credit: $3,552
Premium Credit: $1,725
6000
Expected Contribution
Federal Premium Credit
5000
$1,725
4000
3000
$3,552
2000
$3,275
1000
$1,448
0
200% FPL
300% FPL
cbpp.org
Center on Budget and Policy Priorities
Example: Single Individual
John:
• 24 years old
• Income of 22,980 (200% FPL)
• Expected contribution: 6.3% or $1,448
3 Lowest Cost Silver Plans Covering John:
• Plan A: $4,800
• Plan B: $5,000
• Plan C: $5,200
Benchmark
Premium Credit:
$5,000 - $1,448 = $3,552
cbpp.org
Cost-Sharing Subsidies: Key Points
 Families under 250% FPL receive extra
help with cost-sharing – lower
deductibles and copays
 Actuarial values increased to:
-
94% for families 100-150% FPL
87% for families 150-200% FPL
73% for families 200-250% FPL
 Must select a silver-level plan to qualify
Center on Budget and Policy Priorities
John:
Example 1: Silver Plan Example 2: Bronze Plan
Age:
24
Total Premium:
$5,000
Total Premium:
$3,000
John’s Premium
Contribution:
$121/month
John’s Premium
Contribution:
$0 / month
Plan AV with CSR:
87%
Plan AV without CSR:
60%
Sample Silver-CSR Plan
(enrollee pays)
Sample Bronze Plan
(enrollee pays)
Deductible
$250
$3,000
Maximum
OOP limit
$2,000
$6,350
Inpatient
hospital
$250 /
admission
50% of the charge
$15
$35
Premium Credit:
$3,552
Income:
$22,980
Office visit
cbpp.org
Center on Budget and Policy Priorities
What Happens When Estimated Income for the
Year is Different from Actual Income?
• Final amount of credit based on actual income
• At tax filing time, advance payments received
are reconciled with actual credit amount
– If income increases, may have to repay
– If income decreases, may get more credit at tax
time
• To avoid repayment, can reduce the amount of
advance payment received during the year
cbpp.org
Center on Budget and Policy Priorities
Cap on Amount of Advance Credits that Must Be
Paid Back
Income as
Annual income
percentage of
for an
individual
poverty line
(2013 $)
Under 200%
At least 200%
but less than
300%
At least 300%
but less than
400%
400% and
above
Single
taxpayers
Annual income
Married
for a family of taxpayers filing
four
jointly
(2013 $)
Under $22,980
$300
Under $47,100
$600
$22,980 $34,470
$750
$47,100 $70,650
$1,500
$34,470 $45,960
$1,250
$70,650 $94,200
$2,500
$45,960 and
higher
Full
reconciliation
$94,200 and
higher
Full
reconciliation
cbpp.org
Center on Budget and Policy Priorities
What if an Individual’s Tax Liability is Less than
the Credit Amount?
• Credit is refundable, so people with little or no
tax liability can still get the credit
John:
• Income of 22,980 (200% FPL)
• Eligible for credit of $3,552
• Tax liability of $1,500
Credit ($3,552) will offset tax liability
($1,500), and John will still get
remaining credit ($2,052)
cbpp.org
FAMILY BUDGETS
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