18 comments on “Enhanced Silver – Cost Sharing Reductions

  1. The plan says 87% cost share reduction, does that mean the plan covers 87% of the medical costs?

    cost share reductino

    • 87% is the actuarial value The actuarial value of a health insurance policy is the percentage of the total covered expenses that the plan covers, on average for a typical population. [Age & Zip Code] For example, a plan with a 70% actuarial value means that consumers would on average pay 30% of the cost of health care expenses through features like deductibles and coinsurance. The amount that each enrollee pays will vary substantially by the amount of services they use.

      To find out what the actual expenses are for your plan, click where it says “plan details” and you’ll see the detail on your deductibles, co pays, etc. If you look at the chart on the top of this page, it will show Silver 87 with a $15 office co-pay, $1,400 deductible and the maximum out of pocket of $2,700. Click here for definitions of deductible and OOP Out of Pocket maximum.

  2. I was wondering what is the urgency – deadline to change my plan. My income has increased from $17k to 100k so I no longer qualify for Silver 94 or subsidies.

    So I’m seeing my doctors for $5 co-pay at the moment, does it mean that I’m going to have to pay Blue Shield back the $295/visit of remaining amount that the doctor actually charges (before the negotiated rate) or pay it back in taxes, when I file a 1040 and 8962?

    • Whenever you have a change, you are required to report it to Covered CA within 30 days. Once you have a qualifying event, there is 60 days to change your plan. Covered CA Site…

      The Covered CA application and subsidies are under penalty of perjury… Since, the subsidies are a tax thing… one might call not reporting income and collecting benefits you are not entitled to, tax fraud.

      The payment that Blue Shield makes is probably not $295 on the Doctors bill, but a much lower negotiated rate. I don’t know of any procedure that Blue Shield would recalculate the claim payments. It would just be on the new plan, that you get within 60 days, after the 30 days to report.

      In the past, enhanced silver was funded separately so you didn’t pay that part back, just the subsidy. Now, with the enhanced silver being declared by the courts illegal, the amount of subsidy you pay back, includes the cost of enhanced silver. These calculations are beyond my pay grade. Thus, here’s a calculator.

      When you file taxes, you’ll pay back all the subsidies. Check these pages 1040 8962 and those previously referenced if there are any other penalties.

  3. Can you please confirm the MAXIMUM income for the following:

    (I have the official tables – but they aren’t entirely clear to me)

    Tax year 2017 Silver 94
    2 persons Max income for family of 2 = $

    Tax year 2018 Silver 94 1 person Max income for family of 1 = $

    Bronze HSA
    Max income for family of 1 = $

    • Greater than > Learn More ==> Math is Fun

      Take a look at the chart above and the enlargement below of the part that applies to your question along with the Income Chart and the next screen shot.

      You can earn up to 150% of Federal Poverty Level in this case $18,090 for a single and $24,360 for 2 in the family and still qualify for not only subsidies to pay premiums, but the enhancement – cost sharing reduction to have your Silver 70 increased to better than Platinum as a Silver 94. I’m not sure where your confusion is in reading the chart. If you are more than $18,090 then you are greater than > 150% and would be in Silver 87.

      Please note that if you earn less than 138% of Federal Poverty Level, Medi-Cal will “kidnap” you and I don’t get paid.

      Here’s information on Federal Poverty Level from HHS.gov IRS.gov Code of Federal Regulations 156.400 et seq

      It’s not “income” that we are talking about, but MAGI Income, line 37 + …

      Here’s an explanation on Kaiser Foundation’s Website

      Bronze HSA would not qualify for enhanced silver benefits. Click here to get quote for the subsidy amount, depending on income – federal poverty level.

      See page 174 of Western Poverty Law for explanation of Cost Sharing Reductions

      Be sure that you report changes of income within 30 days

      42 U.S. Code § 18071 – Reduced cost-sharing for individuals enrolling in qualified health plans (2)Additional reduction for lower income insuredsThe Secretary shall establish procedures under which the issuer of a qualified health plan to which this section applies shall further reduce cost-sharing under the plan in a manner sufficient to—
      (A)in the case of an eligible insured whose household income is not less than 100 percent but not more than 150 percent of the poverty line for a family of the size involved, increase the plan’s share of the total allowed costs of benefits provided under the plan to 94 percent of such costs;

  4. Silver 87 was very good. I had a lot of physical therapy PT this past year and silver 87 offered very good prices – benefits for PT.

    Is 87 no longer available?

    If not, are there other plans that offer lower PT then $30 a session?

  5. My mother-in-law just got her medi-cal card having been here for few years. She currently has no income and does not file taxes.

    I have read that on top of medi-cal, she is better off having a Covered Cal Silver plan.

    I do not quite understand. If she has medi-cal, why does she need another coverage?

    Would be obliged if someone explains the details.

  6. What happens if I qualify and sign up for the enhanced silver plan and receive all of the benefits of said plan. [See above chart]

    However, my income is increased at some point in the year for whatever reason and as a result when I file my taxes I am over the income threshold requiring me to pay some of the excess premium payments back with my taxes.

    Is there a penalty for all of the lower deductibles/copays I was able to utilize under the Enhanced silver plan?

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