Skip to main content

This diary is a continuation of my last diary “Obamacare Tax Credits In One Easy Chart” here:

ACA Marketplace Plans: The Metal Levels
...Now, what do I mean by “benchmark Silver” plan? The new Marketplace will have a metal tiered system like the Olympics — Bronze, Silver, Gold and even Platinum health plans. What is covered will be similar for all (remember, all plans must cover 10 essential benefit categories). The difference is how much cost sharing the consumer does.

Bronze plans will pay on average 60% of covered costs, while the enrollee pays 40% up to a certain maximum per year, which for 2014 is $6,350 per individual and $12,700 per family (or even less for lower incomes — see below). Silver plans have a 70/30 split; Gold 80/20; and Platinum 90/10. The Bronze plan will have the lowest premium and highest cost sharing; vice-versa for a Platinum plan. Note that these are averages for the population that has that metal tier, not for you individually. That’s what that wonky term “actuarial value” means.

Depending on how much healthcare you anticipate using, you can opt to pay a higher premium for a Gold or Platinum plan, or a lower premium for a Bronze plan. Whatever you choose, the amount of the federal tax subsidy will be based on the premium for the second lowest Silver plan offered in your state’s exchange. You can apply that subsidy amount toward the plan tier of your choice.

ACA Tax Credits In One Easy Chart
Also, for folks between 100% and 250% of federal poverty level (see incomes expressed as FPL in chart above), there will be tax subsidies to help reduce out-of-pocket costs like deductibles, co-pays, coinsurance and annual maximums in addition to the premium tax credits described in my last post. You MUST purchase a Silver plan to get these extra cost-sharing subsidies because basically the federal govt is paying to upgrade your Silver plan to function like a Platinum-plus, Gold-plus or Silver-plus plan. Here is the cost-sharing split by household income:
100% to 150% FPL:  94% / 6%
(plan and govt pay 94% of covered costs on avg; consumer pays 6%)

150% to 200% FPL: 87% / 13%
(plan and govt pay 87% of covered costs on avg; consumer pays 13%)

200% to 250% FPL: 73% / 27%
(plan and govt pay 73% of covered costs on avg; consumer pays 27%)

What’s more, the maximum annual out-of-pocket (excluding premiums) for lower incomes are reduced below the standard annual max of $6,350 per individual and $12,700 per family:
100% to 200% FPL: Annual max of $2,250 per individual and $4,500 per family
200% to 250% FPL: Annual max of $5,200 per individual and $10,400 per family
Young adults under age 30 will also have the option to purchase a catastrophic plan for even lower premiums (but higher cost sharing if you get sick). Because these plans will have the lowest premiums, no tax credits are available on catastrophic plans.

My prediction is folks are going to have way more choices than they may want to sort through. Fortunately, there will be trained navigators, certified application counselors, and a 24/7 consumer line 1-800-318-2596 to help. Ahhh.... so many choices, so much freedom if you don’t suffer from analysis paralysis!

If you are having trouble logging in at because of all the traffic, you can get an estimate of your premium and tax subsidy at this handy calculator:

You can also check out California’s nifty state-run Marketplace to see how yours might look:
Just type in a California zip code to interact with it. The site is very user-friendly with easy comparison shopping of plans, costs, and tax credits.

Your Email has been sent.
You must add at least one tag to this diary before publishing it.

Add keywords that describe this diary. Separate multiple keywords with commas.
Tagging tips - Search For Tags - Browse For Tags


More Tagging tips:

A tag is a way to search for this diary. If someone is searching for "Barack Obama," is this a diary they'd be trying to find?

Use a person's full name, without any title. Senator Obama may become President Obama, and Michelle Obama might run for office.

If your diary covers an election or elected official, use election tags, which are generally the state abbreviation followed by the office. CA-01 is the first district House seat. CA-Sen covers both senate races. NY-GOV covers the New York governor's race.

Tags do not compound: that is, "education reform" is a completely different tag from "education". A tag like "reform" alone is probably not meaningful.

Consider if one or more of these tags fits your diary: Civil Rights, Community, Congress, Culture, Economy, Education, Elections, Energy, Environment, Health Care, International, Labor, Law, Media, Meta, National Security, Science, Transportation, or White House. If your diary is specific to a state, consider adding the state (California, Texas, etc). Keep in mind, though, that there are many wonderful and important diaries that don't fit in any of these tags. Don't worry if yours doesn't.

You can add a private note to this diary when hotlisting it:
Are you sure you want to remove this diary from your hotlist?
Are you sure you want to remove your recommendation? You can only recommend a diary once, so you will not be able to re-recommend it afterwards.
Rescue this diary, and add a note:
Are you sure you want to remove this diary from Rescue?
Choose where to republish this diary. The diary will be added to the queue for that group. Publish it from the queue to make it appear.

You must be a member of a group to use this feature.

Add a quick update to your diary without changing the diary itself:
Are you sure you want to remove this diary?
(The diary will be removed from the site and returned to your drafts for further editing.)
(The diary will be removed.)
Are you sure you want to save these changes to the published diary?

Comment Preferences

  •  OT (1+ / 0-)
    Recommended by:

    How did this diary earn a Recommended tag with one rec?  Ok, four recs now, but still....

    •  Thank you for removing it. n/t (0+ / 0-)
    •  Urgent Request! (0+ / 0-)

      Which Obamacare exchange insurance network plans offer specialty cancer treatment in any State?
      Please provide a link to the ones not requiring you to go out of network to get help.

      •  Crickets? I found This. (0+ / 0-)

        Loopholes to Skirt Treatment: Cancer Edition

        The American Society has a full-color brochure about how great Obamacare is for cancer patients.

        The myth (from the brochure)

        Taylor Wilhite of Marblehead, Ohio, was diagnosed with acute myeloid leukemia in 2007 at the age of 8. She received three rounds of chemotherapy, had a bone marrow transplant, and at one point was taking 23 pills a day along with many IV medicines. Now age 12, Taylor is in remission. But the costs of her treatment quickly reached her insurance plan’s lifetime benefits cap, leaving her family struggling to pay for the care she needed for the side effects of her treatment.

        The Affordable Care Act does not allow health plans to place lifetime caps on coverage. The law restricts and soon will ban yearly limits. This will give people like Taylor and her family peace of mind that coverage will not suddenly end because of caps on benefits.

        The Reality Scenario:

        Yes! Affordable Care Act removes lifetime caps so my child can have their lifesaving bone marrow transplant! Yayyyyyy.

        Okay, here’s the national registry for locating bone marrow transplant centers. Let’s look them up and go see ‘em and save my baby’s life!

        Okay! So for my Washington state, the transplant centers are Seattle Cancer Care Alliance (SCCA) and VA Puget Sound Health Care System.

        Okay! Well, I’ve signed up for a Blue Cross/Blue Shield plan on the Exchange. BCBS brags of having the largest provider network in the country. And WOW, SCCA is local so we don’t even have to travel!

        Oh, SCCA is not on my provider list, and nor is the VA Hospital? Gee, did I choose the wrong insurance? Well, it’s open enrollment time. I can change. What? None of the insurance companies on my state Exchange have SCCA or VA Hospital in their provider list?

        OMFG!!!!! Well, I guess we’d better not cancel those bake sales and grocery store money collection jars after all.

        End scenario.

        Come on Reality Community!  Let's be honest about what we got:  nothing!
  •  Important diary. Especially the fact that the (7+ / 0-)

    bronze plan will not always be the best plan for people with the least money.

  •  On subsidies (5+ / 0-)
    Recommended by:
    We Won, Lujane, dotdash2u, wader, ladybug53

    Good insight raising the point that in some cases it makes sense for a low-income household (<150 percent of the poverty line) to actually upgrade their insurance from a tax credit perspective. This ought to provide incentives for people to buy good insurance to limit their out-of-pocket costs.  

  •  Some pricing information on Ins. Co websites (2+ / 0-)
    Recommended by:
    Lujane, ladybug53

    The site is still slow. Going to some insurance company sites one can get some information. For example, for Polk county Tx (where a lot of full timing RVers use a mail forwarding service) BlueCrossBlueShield for a 61 year old nonsmoking woman shows a bronze plan for $357/mo with a $6000 deductible then 100% coverage of everything. That uses a HMO. The least expensive PPO is a silver plan with premiums of (if I recall correctly) around $650 and a $6000 deductible. Since we do not domicile there yet, I do not know other companies in the area. This is without any subsidies of course.

  •  This is only part of the ACA decision making (3+ / 0-)
    Recommended by:
    Gooserock, ladybug53, splashoil


    You have to be able to see the actual plans. What doctors, hospitals etc are in the various insurance plans' networks.

    These plans have fewer participating healthcare providers.


    ACA is also causing State Pools to be discontinued. See a very real dilemma facing a Kossack cancer patient. Her diary is: It's official: I cannot keep my doctor with the ACA

    (Sorry I don't know how to link it.)

    She has to make a Solomon's Decision.

    While ACA is great for people with no insurance, there are many being forced to participate who will have to make very hard decisions and need ALL the info about the plans.

    BTW: in Texas I have friends who have coverage under the state pool; they've been trying since 10/1 to get on the site and experiencing nothing but frustration. They even tried calling and that was a dismal failure.

    They need the complete details - not just the costs, but also what each plan covers, what the deductibles are (many are quite high) and so are the premiums for the "better" policies.

    As someone who has been touting ACA since it's inception, I'm personally embarrassed.

    It’s the Supreme Court, stupid! Followed by: It's always the Supreme Court! Progressives will win only when we convince a majority that they, too, are Progressive.

    by auapplemac on Sun Oct 06, 2013 at 03:49:28 PM PDT

  •  a question about hospital stays (3+ / 0-)
    Recommended by:
    Lujane, Mary Mike, ladybug53

    one of my friends sent me an email and said one of the Covered California plans (the Bronze 60) plan stated you had to cover 30% of a hospital stay?  For the Bronze the deductible is $5000 and out of pocket is $6350.  Does this mean once you meet this deductible and then the out of pocket cost insurance kicks in 100% for hospitalization? i am trying to find this out.


    •  Out-of-pocket max now supposed to include... (1+ / 0-)
      Recommended by:

      My understanding is that with the ACA the out-of-pocket(OOP) max per year is now supposed to include any deductibles, co-pays and co-insurance paid by the consumer. In other words, everything except premiums and not covered services (like balance bills from out-of-network providers) should be counted toward the OOP max. That is different than the current system in which co-pays and deductibles have not usually counted.

  •  Also looking for answers on specialty drugs (3+ / 0-)
    Recommended by:
    Lujane, Mary Mike, ladybug53

    it appears, at least in California, they are not covered. I am on Enbrel for Rheumatoid Arthritis which is known as a biological specialty drug. And since Amgen got their patent extended until like 2028 there will be no biosimilar Enbrel on the market.  Medicare does not really cover these types of drugs either. They are super expensive. But really help with RA.

  •  is this correct? (1+ / 0-)
    Recommended by:

    No matter what plan you choose the maximum out-of-pocket for the year is the same?  So in the event of a catastrophic illness, where your bills top $63,000 the coverage would be exactly the same.  Insurance pays all but $6300, for an individual?

    Is it also correct that a yearly gynecological, blood pressure checks etc are all covered 100%?

    •  I was wondering that myself about the max. (1+ / 0-)
      Recommended by:

      If someone anticipates $20,000 in expenses from a pre-existing condition, are they better off paying the lower premium of the Bronze plan since the out of pocket maximums are the same for all plans?

      As to your other question, I'm pretty sure that Obamacare already includes an annual physical, mammogram, colonoscopy, immunizations, birth control and many other things with no co-pay.  I know I didn't have to pay for my colonoscopy last year or mammogram in July of this year.

      This article discusses the preventive services available with no co-pay.

    •  That would have to be verified... (0+ / 0-)

      existing individual plans usually have a deductible, then a separate co-insurance amount (you pay a percentage) until the co-insurance you have paid reaches another $ maximum and than the ins. co pays 100%. So the total you can be out of pocket can vary depending on the plan. Perhaps this has changed with the ACA plans although after seeing some of the Arizona plans, it's still not clear to me.

      Just another faggity fag socialist fuckstick homosinner!

      by Ian S on Sun Oct 06, 2013 at 05:58:45 PM PDT

      [ Parent ]

      •  Out-of-pocket max now supposed to include... (1+ / 0-)
        Recommended by:
        Ian S

        My understanding is that with the ACA the out-of-pocket(OOP) max per year is now supposed to include any deductibles, co-pays and co-insurance paid by the consumer. In other words, everything except premiums and not covered services (like balance bills from out-of-network providers) should be counted toward the OOP max. That is different than the current system in which co-pays and deductibles have not usually counted. I too need to examine more actual plan details as soon as I can access them.

  •  So lets say I estimate $2,000 in medical bills (1+ / 0-)
    Recommended by:

    for the year.

    Under platinum I pay OOP $200 and under bronze it is $800.

    Is this right?

    •  No (0+ / 0-)

      See below.

      "Well, I'm sure I'd feel much worse if I weren't under such heavy sedation..."--David St. Hubbins

      by Old Left Good Left on Sun Oct 06, 2013 at 04:33:59 PM PDT

      [ Parent ]

    •  Deductible has to be satisfied first (0+ / 0-)

      So under any health plan the deductible must be paid and then coverage kicks in. So a family plan with a $6000 individual deductible and a family $12700 (pretty common among the Texas plans I saw) then once you personally hit $6000, the cost sharing comes in (bronze 60% insurance, 40% you, gold 80% insurance, you 20% etc.) But the out of pocket $6350 kicks in pretty fast which is the total you will pay (at least for in network. I do not know about limits to out of pocket out of network costs or specialty drugs not on a formulary). In general we have a Rolls Royce health care system and people with employer subsidized plans have been shielded from a lot of the costs. So we think in terms of insuring a Kia instead of our 18 year old's Corvette.

    •  Those numbers are just averages (0+ / 0-)

      If you only have $2000 in medical costs, under a bronze plan you will probably have to pay most, if not all of it.

    •  The 90, 80, 70, 60 percentage numbers... (1+ / 0-)
      Recommended by:

      are actuarial numbers of what the average person might utilize in the way of health costs. The odds that you will have a catastrophic illness are rather slim; odds are far higher that you might need to see a specialist during the year but of course that doiesn't cost nearly as much as a heart attack. You have to look at the actual plan you're considering to determine how those $2000 in medical expenses would be split between you and the insurance co. The bronze type plan would almost certainly have a deductible higher than $2000.

      Just another faggity fag socialist fuckstick homosinner!

      by Ian S on Sun Oct 06, 2013 at 06:06:11 PM PDT

      [ Parent ]

  •  NOOOOOOO! (0+ / 0-)
    Bronze plans will pay on average 60% of covered costs, while the enrollee pays 40%

    "Well, I'm sure I'd feel much worse if I weren't under such heavy sedation..."--David St. Hubbins

    by Old Left Good Left on Sun Oct 06, 2013 at 04:32:47 PM PDT

Subscribe or Donate to support Daily Kos.

Click here for the mobile view of the site