Budgeting

The budget for APTC, CSR and QHP includes all countable income and all allowable deductions, that number is then compared to the FPL rate for the household, based on tax filing household size.

Qualified Health Plan (QHP)

Applicants may choose to purchase an unsubsidized QHP through Covered CA at full cost to the client. When a client chooses not to request financial assistance on the application there is no MAGI MC, APTC, or CSR evaluation.

Likewise, applicants who do not file taxes in accordance with IRS law (i.e. those who are filing Married Filing Separately or those who received APTC last year but did not file taxes this year) are ineligible for APTC or CSR; however, they can purchase a qualified health plan for the full price.

Advanced Premium Tax Credit

Eligible applicants with income 139% to 400% FPL may be eligible for APTC. However, not all applicants under 400% FPL will receive a tax credit if the plan is considered affordable; the APTC will pay the gap between the full cost of the second-lowest Silver plan and the applicants' monthly maximum portion. Refer to Premiums.

The individual or tax household income determines the APTC amount based on the FPL and family size. APTC allows the individual/tax household to reduce the cost for private health insurance plans purchased through Covered CA. The amount of APTC varies, with those who make less money getting a larger percentage of financial support to lower the cost of their insurance coverage.

To obtain APTC, applicants must enroll in a health plan through Covered CA during open enrollment (or special enrollment).

Example Example Joan makes $5,025/month and has two children who are both her tax dependents. Joan's income ($5,025) is 300% of the FPL for a family of 3. The income is within range for APTC.

Cost Sharing Reduction/Enhanced Silver Plan

In addition to APTC, eligible applicants with income 139% to 250% of the FPL may also receive CSR if they sign-up for the Silver plan, allowing the client to pay less out-of-pocket costs for health services (i.e. lower copayments). Applicants can only have CSR if they also have APTC; CSR cannot exist without APTC.

Applicants who meet the income requirements may be eligible for CSR. This benefit automatically applies if the client signs-up for a Silver plan.

The Cost Sharing Reduction/Enhanced Silver Plan Benefit chart below identifies the income limits for CSR. There are three steps within this program: Silver 94, Silver 87, and Silver 73.

Cost Sharing Reduction/Enhanced Silver Plan Benefit

Number of People in the Household	Silver 94	Silver 87	Silver 73
1	$16,244 - $17,655	$17,656 - $23,540	$23,541 - $29,425
2	$21,984 - $23,895	$23,896 - $31,860	$31,861 - $39,825
3	$27,725 - $30,135	$30,136 - $40,180	$40,181 - $50,225
4	$33,466 - $36,375	$36,376 - $48,500	$48,501 - $60,625
5	$39,207 - $42,615	$42,616 - $56,820	$56,821 - $71,025

Within the CSR program, there are three steps: Silver 94, Silver 87 and Silver 73, the corresponding copayments and deductibles are listed below:

Out‐of‐Pocket Costs ‐ Cost Sharing Reduction/Enhanced Silver Plan Benefit

Key Benefits		Silver 94	Silver 87	Silver 73
Deductible (Medical Deductible)	Individual	$75	$550	$1,900
Deductible (Medical Deductible)	Family	$150	$1,100	$3,800
Primary Care Visit Copayment		$5	$15	$40
Urgent Care Visit Copy		$6	$30	$80
Generic Medication Copayment		$3	$5	$15 or less
Drug Deductible	Individual	$0	$50	$250
Drug Deductible	Family	$0	$100	$500
Emergency Room Copayment (Subject to Deductible)		$30	$75	$250
Annual Out-of-Pocket Maximum	Individual	$2,250	$2,250	$5,450
Annual Out-of-Pocket Maximum	Family	$4,500	$4,500	$10,900

California State Subsidies

The new state subsidies effective January 1, 2020 will only be available through Covered California and can be received in addition to any Federal assistance (APTC, etc.) an individual may qualify for. The amount of financial help received will vary depending on the individual’s age, their annual household income and the cost of health care in their region. The program will limit how much eligible Californians will pay for their premium as a percentage of their income.

Consumers who earn between 400 and 600 percent of the federal poverty level (FPL) will receive an average of $172 per household, per month, which will help them save an average of 23 percent on their current premiums.
Consumers who earn between 200 and 400 percent FPL will receive an average of $15 per household, per month, which will help them save an average of 5 percent off their current premiums.
Consumers who earn less than 138 percent FPL will see their premiums for the benchmark plan lowered to $1 per member, per month.

Individuals can use the Shop and Compare Tool on CoveredCA.com to find out what they would pay for health coverage and whether they qualify for additional financial help under the new law.