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HIV and Enteropathy
Plan Premiums and Pricing

The Affordable Care Act (ACA) set up certain guidelines for the costs to consumers of the plans offered in the State Insurance Exchanges.

Premium Reforms
The ACA eliminated many health insurance plans practices that altered premiums based on discriminating factors, such as gender and pre-existing conditions and made it difficult for many individuals to obtain insurance.
Plans offered in the state Insurance Exchanges will be able to adjust premium prices only for the following factors: age, family size, and tobacco use.
However, premium prices for the health insurance plans will also be highly particular to the state in which the plan is offered.
Actuarial Value:
All plans offered in the Exchanges must cover the Essential Health Benefits. However, plans can vary in the amount of cost-sharing they pass on to consumers.
Plans will be arranged according to categories, based on their actuarial value. The term actuarial value applies to the amount of cost shared by the patient covered by the plan. Cost-sharing can take the form deductibles, co-payments, and coinsurance.
The insurance plan categories are arranged according to low, medium, and high levels of cost-sharing:
  • Bronze level: (actuarial value of 60%)
  • Silver level: (actuarial value of 70%)
  • Gold level: (actuarial value of 80%)
  • Platinum level: (actuarial value of 90%)
An annual out-of-pocket maximum is set by the Internal Revenue Service, and after the out-of-pocket maximum is reached, the plans must cover 100% of services for the remainder of the year.
Out of Network Premiums
These limits set by the ACA only apply to in-network cost-sharing. There are no limits for out-of-network cost-sharing.
HIV patients purchasing insurance in the new Insurance Exchanges will need to take into consideration whether their provider in in-network for their insurance plans.
A number of states have recently released information on what premiums will be in the individual insurance market in 2014. However, these premiums are in effect “sticker prices,” and do not reflect the actual cost that many people will pay after their federal tax credits offset the premium cost.
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