Tag Archives: cost-sharing


Wait – what was that? The idea that people who purchase these plans are expected to share in the costs? Yep, that’s right. However, if you make between 100% and 400% of the poverty level (which, in 2012, is $11,170 for a single person, $23,050 for a family of 4, and more in Alaska and Hawaii) then you are eligible for reductions in cost-sharing, according to section 1402. This reduction varies by precisely how much your income is, but ranges between 1/3rd and 2/3rd .

Cost-sharing, in case you didn’t know, is the co-pay and coinsurance amounts that you often have to pay for health insurance. For example, in my health plan, I pay $25 to see a doctor, and 15% of any procedure performed. These would be my cost-sharing portions. If my household income is less than 400% of the poverty level, then those amounts would be reduced.

There are a couple of special provisions – pediatric dentistry is apparently exempted. In general, if the dental and vision plans are stand-alone, and not bundled with the health insurance, then they are not subject to any requirement of the PPACA. And if a person can be defined as an Indian (language that of the Act, not mine), and has income less than 300% of poverty line, then cost-sharing is eliminated altogether. If you are Not Lawfully Present, then you don’t get cost-sharing reduction. That means no cost-sharing reduction for undocumented peoples.

The next section is a shift in topic, to thinking about eligibility, so we’ll save that as your Friday Fun!


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Moving into the future

The next set of sections are the 1300’s. The main title is “Affordable Coverage for All Americans”. Subtitle – Qualified Health Plans. Another scintillating section, I’m sure.

Sec 1301 – Qualified health plans are ones that are 1) certified 2) provide essential services (remember those guys!) 3) are offered by insurance companies that offer plans in silver and gold. No really, that’s what it says “silver level” and “gold level”. Don’t know what those are – I suppose we will learn that down the road.

Co-op programs offered by the state are included, as well as Medical Home type plans.

Unless specifically identified, self-insured plans are not counted as “health plans”.

I’m sure these details will be debated by health plans (or NOT health plans as the case may be) to get out of these requirements

Sec 1302 – Essential Health Benefits

We talked about these briefly in post “Sorry for the hiatus” but here they are in their own section.

Essential health benefits actually have more to them that offerings. They also have to limit cost-sharing according to the Act, and offer more metalized health plans – bronze, silver, gold and platinum. I’m really looking forward to figuring out what these are.

SO it is up to the Secretary (of Health and Human Services) to define these benefits, but they will be in these categories:

Ambulatory patient services

Emergency Services


Maternity and Newborn Care

Mental Health and Substance use services

Prescription Drugs

Rehabilitative services

Laboratory Services

Preventative, wellness and chronic disease services

Pediatric services – including oral and vision!

This last one is especially interesting, since it wouldn’t require separate insurances for dentistry – and presumably would alter the amounts that are reimbursed. Also, not all insurance plans currently provide maternity care.

It is sometimes argued that people shouldn’t have to pay for other people’s babies, but then health people shouldn’t have to pay for lifestyle induced diseases either then, under that logic. I think we all need to just accept that if we have a health care system at all, we are paying for other people’s choices. If we don’t like it – there are plenty of countries where the medical care is completely non-existent. Move there.

There are then lots of details about how you get certification. The required elements include: not weighting one section more than another; not discriminating against people due to age, disability or expected length of life; take into account diverse health needs; not denying this coverage to individuals (not sure how that is different than discriminating, but then I’m not a lawyer); no pre-authorization of emergency services (whoever once thought up the idea that what you should do when you are getting rushed to the emergency room is call your insurance company is probably 1) rich 2) a real jerk); not charge extra for out-of-network charges; and review this issues.

Cost –sharing gets some treatment as well. Cost-sharing, starting in 2014, shall not exceed $2600 for individuals, and $5150 for families. This is based on 223(c)(2)(A)(ii) of the Internal Revenue Code of 1986, so if that section is updated, so are these numbers. Also, the Act itself allows for increases based on premium increases.

Cost-sharing includes deductibles, co-insurance and copays, but not premiums, charges for out-of-network, or uncovered services.

Aha – we have now come to what the metals mean:

Bronze – plan provides benefits that are actuarially equivalent to 60% of the full actuarial benefits

Silver – plan provides benefits that are actuarially equivalent to 70% of the full actuarial benefits

Gold – plan provides benefits that are actuarially equivalent to 80% of the full actuarial benefits

Platinum – plan provides benefits that are actuarially equivalent to 90% of the full actuarial benefits

I don’t know about you – I like platinum.

Some people (under 30, poor, or those who cannot get affordable coverage otherwise), who may not want expensive metal health insurances, can get catastrophic plans instead. These plans have 0 benefits, until you spend the above numbers, although they do provide 3 primary care visits per year.

So that looks like there is an option for people who don’t really want much health insurance. Kind of like the liability insurance in the car world.


Filed under PPACA