Webinar OE5: Plan Design and Selection

Key Elements of Eligibility and Enrollment

In this webinar presented on September 26, Sarah Lueck, Senior Policy Analyst, and Halley Cloud, Health Outreach Manager, provide an overview of health plan design—including cost-sharing charges in Marketplace plans, eligibility for cost-sharing reductions, and how cost sharing affect costs for consumers—and detail how to evaluate Marketplace plans based on cost sharing and plan design.

This is Part III in a four-part series on key elements of eligibility and enrollment.

Presentation Slides

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Elements of Plan Design

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Premiums vs. cost-sharing charges

Basic elements of plan design

Cost-sharing charges (video section, slides)

  • Types of cost-sharing charges
  • Maximum out-of-pocket (OOP) limit
  • Metal level plan tiers
  • Actuarial value
  • Example: How cost sharing works
  • Individual vs. family cost-sharing
  • In-network vs. out-of-network cost-sharing


Cost-Sharing Reductions

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Definition of cost-sharing reductions (CSR)

  • Eligibility for CSR
  • Comparing CSR variations
  • Zero cost-sharing plans for American Indians and Alaska Natives (AI/AN)


Evaluating Qualified Health Plans

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Summary of benefits and coverage (SBC)

  • Visit limits on covered services
  • Other covered services

Prescription drug formulary

Provider networks


Comparing Plan Options

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Scenario 1: General plan comparison

Scenario 2: Managing chronic diseases (video section, slides)

Scenario 3: Comparing out-of-pocket costs (video section, slides)




Additional Resources

Marketplace Plan Comparison Worksheet | View worksheet

Part I: Premium Tax Credits | View webinar

Part II: Determining Households and Income | View webinar

Part IV: Exemptions | View webinar

Key Facts: Cost-Sharing Charges | View key facts

Key Facts: Cost-Sharing Reductions | View key facts

Beyond the Basics Webinar Series | View all webinars

Key Facts About Health Reform | View all key facts