Individual Health Insurance

• Health insurance provides coverage for the unexpected and large expenses associated with care for an illness or accident
• Sample Hospital Charge (All Texas Hospitals per Texas Price Point 2007-2021):
  
  

Adult – Chest Pain

• Average Length-of-Stay: 2 Days
• Average Charge: $30,497
• Average Charge Per Day: $15,486
• Median Charge: $26,340

Child – Bones, Joints, Muscles, – Lower Leg and Upper Arm Procedures

• Average Length-of-Stay: 2.9 Days
• Average Charge: $68,492
• Average Charge Per Day: $23,315
• Median Charge: $57,082 
  
  
• You receive the negotiated discounts for services prior to meeting your deductible
• Preventive care is covered 100% for the 40 items mandated by the Affordable Care Act

On Exchange Qualifications

• If your household income falls between 100% and 400% of Federal Poverty Level (FPL) Guidelines you will receive a Premium Tax Credit

Off Exchange Qualifications

• If you do not qualify for a premium tax credit or you do not want to purchase coverage on exchange you can purchase coverage off exchange

The Premium Tax Credit helps pay for health insurance coverage bought from the Health Insurance Marketplace.

• When a taxpayer or a family member of the taxpayer applies for coverage, the Marketplace estimates the amount of the PTC the taxpayer may be able to claim for the year of coverage.
• This estimate is based on information the taxpayer provides about family size and projected household income.

Source: IRS – More details about changes for taxpayers who received advance payments of the 2020 Premium Tax Credit

• If you and your spouse work for employers that do not provide affordable health insurance
• Affordability is calculated on 9.61% of employee only coverage
• If the cost of coverage for Employer Sponsored Insurance is above 9.61% of compensation you are eligible for a Premium Tax Subsidy
• You cannot file a Married Filling Separately tax return

# in Household   100% FPL         138% FPL               150% FPL            200% FPL         250% FPL             300% FPL             400% FPL

1                         $12,880               $17,774                 $19,320               $25,760                $32,200               $38,640               $51,520

2                         $17,420               $24,039                 $26,130              $34,840               $43,550                $52,260                $69,680

3                         $21,960                $30,304                $32,940               $43,920               $54,900                $65,880               $87,840

4                        $26,500               $36,570                 $39,750               $53,000              $66,250                 $79,500               $106,000

5                         $31,040                $42,835                 $46,560              $62,080               $77,600                $93,120               $124,160

6                         $35,580                $49,100                 $53,370              $71,160               $88,950                $106,740             $142,320

7                         $40,120                $55,365                 $60,180              $80,240               $100,300             $120,360              $160,480

8                          $44,660                $61,630                 $66,990             $89,320                $111,650             $133,980              $178,640

For households with more than 8, add $4,540 for each additional person.

Eligibility for premium tax credits in coverage year 2021 is based on 2020 poverty guidelines.

FPL = federal poverty line. Source (plus Hawaii and Alaska guidelines): aspe.hhs.gov/poverty-guidelines

Expected Premium Contribution (Coverage Year 2022)

Annual Household Income (% of FPL)

Up to 150% FPL   Expected Premium Contribution (Coverage Year 2022)

200% FPL   2%

250% FPL   4%

300% FPL   6%

400% FPL & Above  8.5%

Source: American Rescue Plan Act Public Law No: 117-2

Family of 5

• Father works for company that does not provide health insurance, Mother stays at home
• Male 27, Female 25, Children (ages 6, 4, and 2)
• 77377 Residence Zip Code
• $65,000 Household Income
• Total Subsidy: $1,148.00 monthly
• Result: Family can use $1,148.00 to purchase a health plan and will pay the difference based on what level of benefits they choose to purchase.

Health Plan Options

• Several $0 premium options with Blue Cross and Blue Shield, Oscar, Bright Health, Friday Health Plans, United Healthcare, and Aetna for $8,700 deductible plans
• Several $300-$500 monthly premium options with Aetna, United Healthcare and Molina for $0 – $3,500 deductibles

• Deductible – The amount you pay before the insurance company starts to share costs
• Co-Insurance – The percentage you pay once you have met your deductible
• Out of Pocket Maximum – The maximum amount you will pay in a calendar year for your portion of eligible medical expenses (per person, max 2 per family)
• Co-Pay – The amount you pay for services such as a doctor visit or prescription
• Preventive Care – Screenings, check-ups, testing that detects serious conditions. Immunizations are included (All Marketplace Plans must cover Preventive Care) 

Traditional Health Insurance

• Deductible
• Co-Insurance
• Co-Pays (Doctor, Prescriptions)
• Preventive Care – 100% Coverage

High Deductible Health Plan (Health Savings Account (H.S.A.) Compatible)

• All charges go to deductible except Preventive Care (covered items)
• Preventive Care – 100% Coverage
• Eligible to have an H.S.A

An H.S.A. is a bank account that you own, can deposit money into and take a tax deduction for your contributions.

2022 Contribution Limits

• $3,650 Individual Coverage
• $7,300 Individual Plus One Dependent (Family)
• If you are age 55+ you can deposit an additional $1,000 in Catch Up contributions.

This is a great way to pay for medical out of pocket with pre-tax dollars!

• Low Utilization – Not many doctor visits and No hospital stays
• Medium Utilization – Few doctor visits and lab work, No hospital stays
• High Utilization – Many doctor visits and lab work, or hospitalization

Look at what you anticipate you will spend on health care in the next calendar year:

• Hospital Stay $__________
• Number of Doctor Visits (Level 1 – Minor Problems)    # of visits ______  X $68 (source: avg. cost per debt.org) = $__________
• Number of Doctor Visits (Level 5 – Complex Medical Problems) # of visits ______ X $234 (source: avg. cost per debt.org) = $__________
• Lab Work/Testing $_________
• Outpatient Surgery $__________
• Prescriptions $__________
• Total Estimated Spend: $__________

• Most all individual health plans have a network of providers that you need to utilize.
• If a plan is a Health Maintenance Organization (HMO) you will need to select a Primary Care Physician (PCP) and utilize this provider for all of your initial services.
• Make sure you select this provider prior to your plan becoming effective. If you do not, the insurance company will assign one for you and it can take up 30 days for a change to become effective.

• A High Deductible Health Plan that is H.S.A. compatible may be a good choice for you. In many cases low utilizers cannot justify the additional cost to justify a plan with co-pays for doctor visits/labs.
• The benefit of a High Deductible Health Plan for a low utilizer is that they can defer the premium savings from a richer benefit plan into an H.S.A.
• Also, keep in mind that most all individual health plans have a similar maximum out of pocket expense. It is how you get to the maximum out of pocket that differentiates the plans.

• A Traditional Plan with a lower deductible and co-pays may be beneficial if you will meet these thresholds. By meeting and exceeding lower deductibles and co-pays this means the insurance company will start to share in your cost that much sooner.
• A High Deductible Health Plan that is H.S.A. compatible may be a good choice for you.
• Also, keep in mind that most all individual health plans have a similar maximum out of pocket expense. It is how you get to the maximum out of pocket that differentiates the plans.

• Notice that this is the same recommendation for Low Utilizers.
• A High Deductible Health Plan that is H.S.A. compatible may be a good choice for you. If you estimate that you will be spending enough to meet and exceed your out-of-pocket maximum this is likely the best choice.
• Having an option to pay your out-of-pocket with pre-tax dollars is advantageous for everyone.
• Also, keep in mind that most all individual health plans have a similar maximum out of pocket expense. It is how you get to the maximum out of pocket that differentiates the plans.

• Aetna
• Ambetter
• Blue Cross and Blue Shield of Texas
• Bright Health
• Community Health Choice
• Friday health plans
• Molina Healthcare
• OSCAR
• United Healthcare