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Cost Sharing Reductions

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Cost-sharing reductions limit the out-of-pocket costs for EHB (Essential Health Benefits) covered by QHPs (Qualified Health Plans) such as deductibles or coinsurance, an individual is responsible for as part of their coverage under a QHP. 

To be eligible for cost-sharing reductions, individuals must:

  • Meet the eligibility requirements for enrollment in a QHP
  • Meet the criteria for eligibility for a premium tax credit
  • Have annual household income at or below 250% of FPL, except for members of federally-recognized Indian tribes, who have special standards
  • Be enrolled in a silver-level QHP, except for members of federally-recognized Indian tribes who have special standards

There are several categories of cost-sharing reductions that are based on annual household income and family size. Each QHP issuer will implement these differently, based on their specific plan design. When an individual is determined eligible for a category of cost-sharing reduction, the plan comparison pages will reflect adjusted cost-sharing requirements of each plan. See the plan details for the cost sharing adjustments.

Summary of Benefits and Coverage and Cost-sharing Reductions

A consumer’s summary of benefits and coverage will summarize the health plan’s benefits that apply to the QHP before taking into account financial assistance the enrollee may receive in the form of cost-sharing reductions. If a consumer is eligible for cost-sharing reductions, the cost sharing (for example, deductibles, coinsurance, or copayments) may be lower than what the consumer sees on his or her summary of benefits and coverage. Consumers who are eligible for cost-sharing reductions can review the cost-sharing information available on the Federally-facilitated Marketplace website or in their health plan’s plan documents to see what their cost sharing might be.

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