Cost-Sharing Reductions

To qualify for cost-sharing reductions, you must:

• have an income below 300% of the Federal Poverty Level, and
• be enrolled in a Silver Plan through Vermont Health Connect

If your income is below 138% of the Federal Poverty Level (FPL), you are eligible for Medicaid (add link to Medicaid page) and will not receive cost-sharing reductions. However, if you have an income below 138% of the FPL and do not qualify for Medicaid because of your immigration or resident status, you can receive cost-sharing reductions.

FPL Guidelines

Cost-sharing reductions are based on FPL guidelines.

You can’t get cost-sharing reductions if you have an offer of health insurance through your employer or through your spouse’s employer that is “affordable and adequate.”

Is My Plan “Affordable” and “Adequate”?

• A health plan is “affordable” if a plan covering just the employee costs 9.83% or less of your total household income. This test does not consider the cost to cover anyone else in the family. Use this Affordability Estimator to figure out if your health plan from work is affordable.
• A health plan is “adequate” if it has an “actuarial value” of at least 60%. You can ask your employer if their plan meets this test.

You can tell Vermont Health Connect about your employer’s plan and they will tell you if you are eligible for financial help. Call Vermont Health Connect at 1-855-899-9600.

Young adults under age 26 can be eligible for cost-sharing reductions even if you have an offer of insurance through:

• a parent’s insurance, and/or
• your college or university (as long as you have not accepted the offer)

If your income is below 300% of the Federal Poverty Level, you will automatically get cost-sharing reductions if you sign up for a Silver Plan. The lower cost-sharing amounts will be on the plan information you get from Vermont Health Connect.

You do not have to keep track of your spending or pay for services and wait to get paid back.

If your income goes up or down during the year, you should let Vermont Health Connect know right away so you will get the right benefits.

A number called an Actuarial Value (AV) tells us how much medical spending is paid by the health plan compared to the amount paid out-of-pocket by the consumer. The AV tells the percentage of a typical population’s costs that would be covered under the plan. It does not tell the percentage of an individual’s costs that are covered.

According to the law:

• Platinum Plans must have a 90% Actuarial Value
• Gold Plans must have a 80% Actuarial Value
• Silver Plans must have a 70% Actuarial Value
• Bronze Plans must have a 60% Actuarial Value

In order to get cost-sharing reductions, you have to enroll in a Silver Plan. If you qualify for cost-sharing reductions, your AV in a Silver Plan will be higher. For example:

• If your income is at or below 150% of the Federal Poverty Level, your Silver Plan will have a 94% AV (higher than Platinum Plans)
• If your income is between 151 and 200% of the FPL, your plan will have an 87% AV (higher than Gold Plans)
• If your income is between 201 and 250% of the FPL, your plan will have a 77% AV (higher than Silver Plans without cost-sharing reductions)
• If your income is between 251 and 300% of the FPL, your plan will have a 73% AV (higher than Silver Plans without cost-sharing reductions)

What does this mean for you? Even though you have to enroll in a Silver Plan to get cost-sharing reductions, your plan will have a higher AV and you won’t have to pay as much out of your own pocket for health care services.