How do Cost-Sharing Subsidies work?
Cost-sharing subsidies will reduce your out-of-pocket cost, including your co-payments, co-insurance, deductibles, and out-of-pocket maximum. View chart. These are the costs you have to pay when you get health care. The amount of the reduction (the amount of cost-sharing subsidies) you can receive is based on your income and family size. If you are eligible for premium assistance and your annual household income is between 138% and 250% of the federal poverty, you can qualify for cost-sharing subsidies.
It is important to note that if you are eligible for cost-sharing subsidies, you will also receive premium assistance.
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However, and unlike premium assistance, you cannot receive cost-sharing subsidies in any metal tier level, but ONLY if you enroll in a silver-level plan. Once Covered California determines that you are eligible for cost-sharing subsidies, you will be able to select one of the Enhanced Silver-level plans, based on your income level.
How do I get my cost-sharing subsidies?
If you select a silver-level plan, your cost-sharing subsidies will be automatically applied when you use your health care benefits. For instance, when you go to see your doctor, the price of your visit will be automatically reduced and you will only have to pay the reduced costs.
(a) General requirement. A QHP [Qualified Health Plan] issuer must ensure that an individual eligible for cost-sharing reductions, as demonstrated by assignment to a particular plan variation, pays only the cost sharing required of an eligible individual for the applicable covered service under the plan variation. The cost-sharing reduction for which an individual is eligible must be applied when the cost sharing is collected.
(b) Assignment to applicable plan variation. If an individual is determined to be eligible to enroll in a QHP in the individual market offered through an Exchange and elects to do so, the QHP issuer must assign the individual under enrollment and eligibility information submitted by the Exchange as follows—
(1) If the individual is determined eligible by the Exchange for cost-sharing reductions under §155.305(g)(2)(i), (ii), or (iii) of this subchapter (subject to the special rule for family policies set forth in §155.305(g)(3) of this subchapter) and chooses to enroll in a silver health plan, the QHP issuer must assign the individual to the silver plan variation of the selected silver health plan described in §156.420(a)(1), (2), or (3), respectively.
(4) If the individual is determined by the Exchange not to be eligible for cost-sharing reductions (including eligibility under the special rule for family policies set forth in §155.305(g)(3) of this subchapter), and chooses to enroll in a QHP, the QHP issuer must assign the individual to the selected QHP with no cost-sharing reductions. ECFR.Gov
§156.410 Cost-sharing reductions for enrollees.
§156.420 Plan variations.
§156.425 Changes in eligibility for cost-sharing reductions.
§156.430 Payment for cost-sharing reductions.
§156.440 Plans eligible for advance payments of the premium tax credit and cost-sharing reductions.
§156.460 Reduction of enrollee’s share of premium to account for advance payments of the premium tax credit.
§156.470 Allocation of rates for advance payments of the premium tax credit.
§156.480 Oversight of the administration of the cost-sharing reductions and advance payments of the premium tax credit programs.
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