Premium and Cost-Sharing Flashcards

Cost-sharing reductions (CSR) improve coverage for eligible individuals by:

Answer: Lowering deductibles, copayments, and out-of-pocket maximums within a Silver plan

CSRs reduce the cost-sharing features within a Silver plan—including deductibles, copays, coinsurance, and the out-of-pocket maximum—for eligible low-income enrollees.

At 150% FPL, a CSR-eligible enrollee in a Silver plan would have an actuarial value of approximately:

Answer: 94%

Enrollees with incomes between 100–150% FPL in a CSR Silver plan receive the highest level of CSR, boosting the actuarial value to approximately 94%.

What is the minimum value standard for employer-sponsored health insurance under the ACA?

Answer: 60% actuarial value

An employer-sponsored plan meets 'minimum value' if it covers at least 60% of the total allowed cost of benefits, equivalent to a Bronze plan's actuarial value.

For employer-sponsored coverage to be considered 'affordable' under the ACA in 2025, the employee's share of self-only premium must not exceed what percentage of household income?

Answer: 9.12%

For plan years beginning in 2025, employer coverage is considered affordable if the employee's self-only premium does not exceed 9.02% of household income.

A member has a $2,000 deductible and 20% coinsurance with a $6,000 out-of-pocket maximum. After paying the deductible, they incur $20,000 in additional covered charges. What is their total out-of-pocket cost?

Answer: $6,000 (capped at OOP max)

Once the out-of-pocket maximum of $6,000 is reached (deductible + coinsurance), the plan covers 100% of additional costs, so total cost is capped at $6,000.

Under the ACA, cost-sharing for recommended preventive services must be waived for which plan types?

Answer: Non-grandfathered individual and employer group plans

The ACA's preventive services mandate applies to non-grandfathered group health plans and individual health insurance coverage, including self-funded employer plans.