Covered California Cost Sharing Reductions

Eligible Income Level 133% to 250% FPL

Eligible Californians who buy health care coverage through an Covered California will have a cap on their total out-of-pocket spending, including deductibles, co-pays and co-insurance. These limits are based on the out-of-pocket limits that apply to high-deductible plans used with Health Savings Accounts (HSAs). People with incomes under 400 percent FPL will get subsidies to lower those caps based on their income.

Out-of-Pocket Spending Limits for Consumers Based on Income

  • 133% - 200% FPL - $2,240/individual or $4,500/family
  • 200% - 250% FPL - $5,200/individual or $10,400/family
  • 250% and Above - $6,400/individual or $12,800/family

Lower Deductibles and Copays

In addition to the federal premium subsidies called advanced tax credits, health plans will reduce point-of-service cost-sharing for individuals in families with incomes between 100% and 250% of FPL who purchase Silver Level coverage through the Covered California health insurance marketplace. The cost-sharing reductions will lower the maximum out-of-pocket limits and reduce other cost-sharing components, such as deductibles, copays, and coinsurance. The chart below illustrates the cost reductions associated with lower income levels. (Click image to enlarge.)

SLIDING SCALE BENEFITS.png

Higher Actuarial Value

The US Department of Health and Human Services (HHS) will pay for the value of the cost sharing reductions to the health plan issuing the coverage to the individual whose cost sharing was reduced. HHS has indicated its intent to require Covered California or health plans to make available three variations of each standard silver plan to correspond with the out-of-pocket and actuarial value requirements shown in the above chart. Thus, an individual with income of 175% FPL will be offered a modified silver plan with a richer average benefit value (88% actuarial value compared to 72% for the regular silver plan), by limiting their out-of-pocket expenses to one-third the amount of the regular silver plan as required by the reduced cost-sharing rules.

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