Lesson 5 of 8
In Progress

Types of Financial Assistance

Collin Gabriel November 30, 2021

Marina Cassandra (00:00):

So the types of financial assistance you can receive from the marketplace on these individual plans come in a couple of different forms. Like we mentioned, there are premium tax credits and they help consumers pay for the premiums, the monthly amount that we pay for that coverage. Then the out of pocket costs are referred to as cost sharing. And there’s a reduction in how much the consumer needs to pay when they seek services, if their income is lower. So it’s on a sliding scale, there’s different levels of cost sharing reductions, and there are different amounts of premium tax credits based on the household income.

Collin Gabriel (00:40):

Oh, marina, can we go back to that one real quick? I just, just wanted to clarify and, you know, I think you and I had chatted about this previously. So I think that to put it in a context, if we acquire, uh, a plan and, uh, the, uh, monthly cost of that plan is say $450, excuse me. And then every time we go to the doctor, there’s, uh, a copay of $45, the premium tax credits would help reduce my $450 monthly down to a potentially down to a lower sum like $200 a month or $100 a month. Is that correct?

Marina Cassandra (01:22):

That is Correct.

Collin Gabriel (01:23):

And then for the cost sharing reductions, the CSRs, if every time we have to go in it’s $45, it traditionally, um, if I, uh, received cost sharing reductions that could go as low as, you know, $20, it could change and become lower. Is that that’s the idea?

Marina Cassandra (01:43):

Yeah. You’ve got a great understanding of that. And of course, how much lower it will be, obviously depends on the income level for the household.

Collin Gabriel (01:52):


Marina Cassandra (01:52):

See, on the next slide here, um, we don’t have the household prizes, but, uh, typically if you visit an assister or an agent, they will have access to these numbers. You can also get them on, um, healthcare.gov or, um, cms.gov, which is Centers for Medicaid and Medicare Services. But basically if your household size and income is at 305% of the federal poverty level, all the children up through age 18 could qualify for the Oregon Health Plan. And now this is the Starlight immigration status. So all kids through age 18, living in Oregon with a household income of 305% can qualify for the Oregon health plan, um, or CHIP, which is Medicaid and/or CHIP also, uh, pregnant adults who live in a household at up to 190% of household income, regardless of immigration status can also qualify for OHP during the time that they are pregnant. And for two months after that.

Marina Cassandra (03:01):

So these two are regardless of immigration status, those are based on legislation that have, uh, passed them last few years. Um, and then Oregon or Oregon health plan for adults age 19 through 64. So, um, that would be in a household of 138% of federal poverty level. So these are the, these are basic levels. There are other more intricate, um, less, less, um, common federal poverty levels that can qualify for different kinds of Medicaid, such as, um, folks who are getting Medicare and need help paying for coverage. So for the purposes of our, our work today, we want to, you know, what the average family, um, what their federal poverty level, who could qualify them for.

Marina Cassandra (03:55):

Now, if you are anywhere between 139% and 250%, that’s where those cost sharing reductions come in. And if you’re between 139% and several hundred percent, uh, four or 500%, even of the federal poverty level, you can qualify for tax credits.

Marina Cassandra (04:16):

So up to 250%, you could get both, but when you’re above the 250% FPL level, then you would only potentially qualify for the tax credits. Now the, um, the premium tax credits are the same for general population and for members of federally recognized tribes. What’s different and, um, significantly different and really important to share is that the cutoff is not 250 it’s 300% and there’s no variable cost sharing. It is zero cost sharing. So, um, a member of a federally recognized tribe, and it doesn’t have to be an Oregon tribe, but if they’re an enrolled member of any federally recognized tribe, they, uh, they can qualify for zero cost sharing. So that means, um, from, from a household income of 139 to 300%, any plan they choose, they can get zero cost sharing. Now why this is one of the ways that this is significant is that it’s not a reduction in what they pay.

Marina Cassandra (05:28):

They pay zero for all covered services up to 300% of the, of the federal poverty level. And that is for covered services. And that premium tax credit can be applied to the lowest cost plan. General population in order to get the costumes and reductions that must be applied to a silver level plan, but the Bronx level plans are typically low, premium and high deductible. Doesn’t matter, you can apply that entire premium, which is on silver plan. You can, uh, apply that entire tax credit to a bronze level plan to get the deepest discount on that premium, that monthly premium, and still pays zero at the doctor, whether you’re at an Indian health care provider or referral to, um, you know, a specialist or you decide that you’re going to get your primary care wherever you want. Um, all covered services at this point are covered at a hundred percent by the insurance company, and it can even be an out of network provider. So, um, that’s pretty significant.

Marina Cassandra (06:39):

Limited cost sharing is a little bit different. There is no cap on limited cost sharing, but it is any amount, 300% and over, and the concept is similar. Uh, getting, you know, not having to pay anything for covered services, however, you need to get a referral from an Indian health care provider. So for example, if I’m an enrolled tribal member and I have access to a tribal clinic, I will probably get my primary care there. Um, but if I need anything that can’t be done in the four walls of the clinic, they can give me a referral. And what’s significant about this too, is that the, the clinics pay for those referrals. If someone is uninsured and doesn’t have Medicaid or Medicare and no insurance, the clinic pays for that, but they, if they can refer to someone who has coverage, that’ll be paid at a hundred percent with that referral.

Marina Cassandra (07:38):

And the clinic does not have to pay for the coverage. The insurance company will. So it’s good for the it’s good for the clinic. And it’s good for the consumer as well. One thing that, um, is also takes place in a lot of different tribes around the country. Um, we have one in Oregon that also participates is the tribal premium assistance program, TPSP. And what they do, uh, Klamath is the one tribe in Oregon that participates in this. And what they do is they have a roster of, um, community members that they pay the balance of the premium after the tax credit or the entire premium, each tribe can set their own criteria for who they’re going to cover and how much, but, um, in those cases, there is no premium for the consumer and it is zero and the, and the coverage is zero. So these are, um, just kind of an overview of the cost protections that are provided for members of federally recognized tribes through the affordable care act.

Duane Lane (08:45):

What are the options for an adult, a DACA person? Is it private only? And that’s it

Marina Cassandra (08:53):

Correct? Basically. Um, if somebody who has DACA status, they would have to consult an agent and, and get, uh, a direct purchase plan, some other, yeah. Something with maybe an association plan that would be possibly more affordable, but again, not cover everything.