The federal poverty level (FPL) - also referred to as the federal poverty guidelines – is used to determine eligibility for Medicaid and CHIP, and for premium subsidies and cost-sharing reductions in the health insurance marketplace.| healthinsurance.org
If you're like the vast majority of consumers, you may be hearing about CSRs for the first time and wondering why these subsidies are so important, and whether they actually affect your own coverage. Here's what you need to know:| healthinsurance.org
An out-of-pocket maximum is a predetermined, limited amount of money that an individual must pay before an insurance company or (self-insured employer) will pay 100% of an individual's covered, in-network health care expenses.| healthinsurance.org
The monthly premiums you pay in order to have coverage are not included in out-of-pocket costs. Out-of-pocket costs are only incurred if and when you need medical care, whereas premiums have to be paid every month, regardless of whether you need medical care or not.| healthinsurance.org
There are two different meanings for the term benchmark plan – and both have to do with the Affordable Care Act: Benchmark plan is the term used to describe the second-lowest-cost Silver plan (SLCSP) available in the exchange/Marketplace, and it’s also the term for the plan that each state designates as the standard for essential health benefits (EHBs).| healthinsurance.org
Immigrants can enroll in ACA-compliant individual health insurance just like any other lawfully present U.S. resident. Lawfully present immigrants are eligible for premium subsidies.| healthinsurance.org
While the Affordable Care Act's premium subsidies help pay the cost of the health insurance itself, cost-sharing subsidies help to reduce out-of-pocket spending for eligible enrollees when they select Silver plans. The Trump administration eliminated federal funding for cost-sharing reductions, but the benefits are still available to eligible enrollees. And because the cost of cost-sharing reductions has been added to premiums, premium subsidies are much larger than they were prior to 2018.| healthinsurance.org
Under the Affordable Care Act, eligibility for Medicaid, premium subsidies, and cost-sharing reductions is based on modified adjusted gross income (MAGI). But the calculation for that is specific to the ACA – it's not the same as the MAGI that's used for other tax purposes| healthinsurance.org
The Affordable Care Act standardized individual health insurance policies by creating a “metal” ranking for individual/family and small-group policies, based on their actuarial value (the percentage of costs that the plan pays across a standard population).| healthinsurance.org
From 2015 through 2021, the IRS did make an annual change — usually quite small — to the percentage of income that you have to pay for self-purchased (individual/family) health coverage. But there’s a lot more to it than just the percentage of income that the IRS says you have to pay for the benchmark plan.| healthinsurance.org
