Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 1 of 29 UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA STATE OF CALIFORNIA, et al., Case No. 17-cv-05895-VC Plaintiffs, ORDER DENYING MOTION FOR PRELIMINARY INJUNCTION v. DONALD J. TRUMP, et al., Defendants. The Affordable Care Act requires health insurance companies to subsidize the cost of copayments and deductibles for lower-income people. In turn, the Act requires the federal government to make advance payments to the companies to cover the cost of this subsidy. The legal problem in this case is that while the Act requires the insurance companies to be paid, it's unclear whether the Act actually appropriated money for these payments. If Congress doesn't appropriate money for a program, the Constitution prohibits the executive branch from spending money on that program – even if Congress previously enacted a statute requiring the expenditure. The Obama Administration took the position that the Affordable Care Act indeed appropriated money for the payments, so it drew funds from the U.S. Treasury every month to make them. The Trump Administration initially continued this practice, but has now concluded that the Act did not actually make the necessary appropriation. So the Trump Administration has terminated the payments, at least until Congress decides to appropriate the money. In response, the State of California, along with 17 other states and the District of Columbia, filed this lawsuit, contending the Obama Administration was right. They seek an Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 2 of 29 emergency ruling requiring the Trump Administration to continue making the payments while the lawsuit is pending. This request is denied. First, although the case is at an early stage, and although it's a close question, it appears initially that the Trump Administration has the stronger legal argument. Second, and more importantly, the emergency relief sought by the states would be counterproductive. State regulators have been working for months to prepare for the termination of these payments. And although you wouldn't know it from reading the states' papers in this lawsuit, the truth is that most state regulators have devised responses that give millions of lower-income people better health coverage options than they would otherwise have had. This is true in almost all the states joining this lawsuit. Including California, whose regulators issued a press release just days before the suit explaining how so many lower-income people will benefit. I. The central purpose of the Affordable Care Act is to provide health coverage for the millions of people who don't get it through their jobs. Six years after its enactment in 2010, the Act is well on its way to achieving that purpose: almost half of the previously uninsured people in the United States now have coverage. 1 Some people have coverage because the Act expanded Medicaid eligibility. 2 Many others have purchased insurance, usually on new insurance "exchanges" where people can shop for coverage. Three key policies acting in concert have enabled the Act's success: (1) the Act bars insurance companies from denying coverage to people or charging them more based on their health status; (2) the Act requires people to buy insurance; and (3) the Act provides significant subsidies to help lower-income people buy insurance on the exchanges. It cannot reasonably be disputed that, for the Affordable Care Act to achieve its 1 See Robin A. Cohen et al., National Center for Health Statistics, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2016 at 2 (May 2017), https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201705.pdf [https://perma.cc/W2TPL9RK]. 2 Around 15 million people were covered by the expansion of Medicaid in 2016. Medicaid Expansion Enrollment, Timeframe: FY 2016, Kaiser Family Foundation, https://www.kff.org/health-reform/state-indicator/medicaid-expansion-enrollment [https://perma.cc/EWQ4-MUZ5]. 2 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 3 of 29 goals, all three of these pillars must remain standing. See King v. Burwell, 135 S. Ct. 2480, 2485, 2487 (2015). Lower-income people have access to two forms of subsidies to help them afford insurance sold on the exchanges. The most significant subsidy is a tax credit to help offset the cost of monthly insurance premiums: people whose income puts them between 100% and 400% of the federal poverty level receive significant tax credits to alleviate the cost of buying insurance. (The federal poverty level for a single person is a mere $12,060 per year.) 3 To use an example of how the tax credit works on the exchanges, in San Francisco, a 60-year-old making around $45,000 in 2017 could purchase a fairly typical plan for around $360 per month – even though the actual premiums would be $940 per month absent the tax credits. 4 A large majority of people who purchase health care on the exchanges rely on these tax credits. 5 The premium tax credit is structured so you get it in advance, when you are actually paying your insurance premiums. Although normally with tax credits you have to wait for the benefits until your tax returns are filed the following year, the Affordable Care Act established a system through which your tax credit is estimated and paid in advance to the insurance companies, so they can reduce your premiums by a corresponding amount. If, after the year is over, there is a discrepancy between the discount you received and the amount of your premium tax credit, it is reconciled through your tax returns. 26 U.S.C. § 36B(f). In fact, when you're shopping for insurance on the exchange – at least in California – you are not even told the amount of monthly premium before the tax credit. You're simply told the amount you're required to pay. 6 3 Annual Update of the HHS Poverty Guidelines, 82 Fed. Reg. 8831, 8832 (Jan. 31, 2017). App. B at 2, 5; 2017 QHP Individual Rates, Covered California, http://hbex.coveredca.com/data-research/library/2017_QHP_Individual_Rates_File_for_ Posting_100716.xlsx [https://perma.cc/2MT6-EH3D]; see also 26 U.S.C. § 36B(b)(2)(B). 5 In March 2016, 84.7% of people who purchased health care on the exchanges received the tax credit. March 31, 2016 Effectuated Enrollment Snapshot, Centers for Medicare & Medicaid Services, https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheetsitems/2016-06-30.html [https://perma.cc/3ESH-M44Z]. 6 See, e.g., App. B at 4-6, 9-11. 4 3 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 4 of 29 The other subsidy – the one that's the subject of this dispute – reduces the amount that lower-income people have to pay out-of-pocket when they use their insurance to get care. When you have insurance, you typically make "co-payments" when you visit the doctor or pick up medications from the pharmacy. Sometimes you also have a "deductible," which means that you must pay the full cost of your health-care expenses until you reach the deductible amount, at which point your insurance kicks in and covers the rest. You also might be required to pay "coinsurance." Co-insurance is triggered after you've reached your annual deductible and requires you to pay a percentage, say 20%, of your doctor's bill or the price of your medications; the insurance company pays the remaining share. The Affordable Care Act refers to these payments as "cost-sharing" payments, because you are sharing the cost of your treatment with your insurance company. The subsidy provided by the Act is called a "cost-sharing reduction," because the insurance companies are forced to reduce your cost-sharing payments. Specifically, the Act requires insurance companies to offer plans to lower-income people with reduced cost-sharing payments. People whose income puts them between 100% and 250% of the federal poverty level can buy plans of this type. In turn, the Act requires the federal government to compensate the insurance companies for those reductions. Typically, people refer to the payments by the federal government to the insurance companies as "cost-sharing reduction payments," or "CSR payments." Throughout this opinion, the phrase "CSR payments" references these payments that the federal government is required to make to the insurance companies. As with the tax credits, the Act provides that the federal government will pay for these subsidies in advance. Specifically, the federal government estimates in advance the amount of subsidy to which you are entitled and makes a CSR payment in that amount to your insurance company. As a result, the insurer can reduce your cost sharing by a corresponding amount throughout the year on the federal government's dime. If, after the year is over, you ended up using less money from the subsidy than what the federal government gave the insurance company, the insurance company must return the excess to the federal government. See 45 4 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 5 of 29 C.F.R. § 156.430(e)(2). The premium tax credits and the cost-sharing reductions work together: the tax credits help people obtain insurance, and the cost-sharing reductions help people get treatment once they have insurance. In 2016, the federal government spent $32 billion on premium tax credits, and these credits helped around 10 million people purchase insurance on the exchanges. For the same year, it spent $7 billion on CSR payments to insurance companies, which helped 7 million people pay for doctor's visits, medications, and other treatment. 7 Following passage of the Affordable Care Act, and once the exchanges were ready to get up and running, an issue about the statutory language arose. For the premium tax credits, the language of the Act was clear: it required the tax credits to be paid, and made a "permanent appropriation" for those tax credits, meaning the money would automatically be available each year for the executive branch to fulfill its duty to make the payments. But for the cost-sharing subsidies, the language of the Act was different. It required the insurance companies to give people the reductions, and it required the federal government to pay the insurance companies in advance for these reductions, but it did not explicitly make a permanent appropriation for the CSR payments to the insurance companies. Absent a permanent appropriation, the responsibility would be on Congress to help fulfill the federal government's obligation to make the CSR payments by providing money through the annual appropriations process. In 2013, the Obama Administration concluded that the Act could be interpreted as implicitly making a permanent appropriation for CSR payments, meaning that no annual appropriations were required. So, beginning in January 2014, the Administration began drawing money from the U.S. Treasury to make those payments on a monthly basis, just as it did for the 7 Congressional Budget Office, Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2016 to 2026 31, tbl. 2 (2016), https://www.cbo.gov/sites/default/files/114thcongress-2015-2016/reports/51385-healthinsurancebaselineonecol.pdf [https://perma.cc/M3S78X53]; 2017 Marketplace Plan Selections with Financial Assistance, Kaiser Family Foundation, https://www.kff.org/health-reform/state-indicator/2017-marketplace-plan-selections-byfinancial-assistance-status [https://perma.cc/VX6G-Q47Z]. 5 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 6 of 29 premium tax credits. In contrast, the House of Representatives took the position that the Act contained no permanent appropriation for CSR payments. Because Congress was not making annual appropriations, the House believed the Administration was violating the Constitution by making payments to the insurance companies for which money had not been appropriated. See U.S. Const. art. I, § 9, cl. 7 ("No money shall be drawn from the Treasury, but in Consequence of Appropriations made by Law . . . ."). Accordingly, in November 2014, the House filed a federal lawsuit against the Obama Administration in Washington, D.C., to stop the allegedly unconstitutional payments. In May 2016, United States District Judge Rosemary Collyer ruled in favor of the House, concluding the Act had made no permanent appropriation for the federal government to make CSR payments. As a result, Judge Collyer concluded, the Administration could not (absent annual appropriations or an amendment to the Affordable Care Act providing for a permanent appropriation) continue to make the CSR payments. U.S. House of Representatives v. Burwell, 185 F. Supp. 3d 165, 168 (D.D.C. 2016). However, Judge Collyer stayed her ruling so the federal government could continue making the payments while the Obama Administration pursued an appeal of her ruling in the D.C. Circuit. Id. The Obama Administration therefore continued making payments. Then the election happened. Shortly afterward, on November 21, 2016, the House asked the D.C. Circuit to stay the appeal. Appellee's Motion to Hold Briefing in Abeyance, U.S. House of Representatives v. Burwell, No. 16-5202 (D.C. Cir. Nov. 21, 2016). The House explained that, in light of public statements by members of the incoming Trump Administration, it believed that the executive branch might reconsider its legal position on the validity of the payments. Given that, the House asserted that it might be a waste of time to keep moving forward on an appeal the new Administration might eventually drop. Id. at 3-4. The D.C. Circuit granted the motion in December 2016 and stayed the case. Order Granting Motion to Hold in Abeyance, U.S. House of Representatives v. Burwell, No. 16-5202 (D.C. Cir. Dec. 5, 2016). In spring 2017, 17 states (including most of those bringing the current lawsuit) and the District of Columbia sought to intervene in the D.C. Circuit appeal. Their argument for 6 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 7 of 29 intervention was that: (i) they believed the Affordable Care Act had made a permanent appropriation for CSR payments; (ii) it appeared the Trump Administration was prepared to renounce that position, leaving nobody in the case to argue it; and (iii) the states would be harmed if the payments stopped. In August 2017, the D.C. Circuit granted the states' motion. It concluded that the states had standing to intervene because they would be injured by any decision to terminate the payments, and that the states' participation in the appeal was needed to ensure that someone would continue to argue the position previously taken by the Obama Administration in the case. Order Granting Motion to Intervene, U.S. House of Representatives v. Price, No. 16-5202 (D.C. Cir. Aug. 1, 2017). But the D.C. Circuit kept the stay in place, apparently awaiting the Trump Administration's decision about whether it would change its position in the case. Meanwhile, seeing the writing on the wall, states throughout the country began working with insurance companies early in 2017 to prepare for the likelihood that the Trump Administration would switch positions and stop making the CSR payments. The problem was that even if the payments to the insurance companies stopped, the Affordable Care Act would still require the companies to provide the cost-sharing reductions to patients enrolled in certain plans. To offset this cost increase, insurance companies would want to raise premiums for 2018 insurance coverage. And if the companies did not believe they'd be able to offset the costs through premium increases, they might withdraw from the exchanges for 2018. Withdrawal by an insurance company would be especially harmful if it was the only company offering plans on an exchange for a given region: although people can buy insurance "off-exchange," they are only eligible for premium tax credits or cost-sharing reductions if they purchase insurance on an exchange. See 42 U.S.C. § 18071(b)(1); 26 C.F.R. § 1.36B-2(a)(1). So most states went to work with the insurance companies to try to figure out a way the companies could increase premiums to make up for the expected termination of the CSR payments. Their efforts are described more fully in Section IV below. On October 11, 2017, the anticipated termination of the CSR payments became a reality. 7 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 8 of 29 The Attorney General sent a letter to the Treasury Department and the Department of Health and Human Services, explaining his view that the Affordable Care Act had not made a permanent appropriation for the CSR payments, and that the agencies therefore were precluded from making them. Notice at 6, U.S. House of Representatives v. Hargan, No. 16-5202 (D.C. Cir. Oct. 13, 2017). The next day, the White House announced this decision to the media. The day after that, October 13, the Justice Department filed a notification with the D.C. Circuit, informing it of the decision. Id. Also on October 13, the State of California, along with 17 other states and the District of Columbia, filed this lawsuit in San Francisco. They allege the federal government is required under the Affordable Care Act to make the CSR payments to the insurance companies, that the Act permanently appropriated the money to make these payments, and that the Administration is therefore violating the law by refusing to make them. On October 18, the states filed a request for a temporary restraining order that would force the Administration to make the payments. The states sought a ruling by 4 p.m. on October 19, because the insurance companies had been anticipating the next round of payments on October 20. During a telephonic conference with the parties, the Court declined to issue a ruling on such a tight time frame and without receiving a response from the Administration. Instead, the Court scheduled a hearing for October 23. Since then, both sides have agreed that the TRO application should be converted to a motion for a preliminary injunction. Therefore, the question presented by this motion is whether the Court should issue a preliminary injunction requiring the Administration to make the CSR payments to the insurance companies while this case is pending, rather than wait until the case is fully adjudicated before deciding what relief (if any) is appropriate. II. The Administration believes that two procedural defects in the states' lawsuit prevent the Court from even inquiring whether to issue a preliminary injunction. The current record reveals no such defects. First, the Administration contends the states lack standing under Article III of the 8 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 9 of 29 Constitution to bring this case in federal court, because they have failed to allege any direct injury from the decision to terminate the CSR payments. See Lujan v. Defenders of Wildlife, 504 U.S. 555, 560-62 (1992). But the states allege – among other harms – that they have incurred and will continue to incur administrative costs because of the disruption to the exchanges caused by the federal government's decision to stop CSR payments. And the states have presented evidence to back up those allegations. These costs are enough to satisfy the standing requirement. See West Virginia v. EPA, 362 F.3d 861, 868 (D.C. Cir. 2004); see also Texas v. United States, 787 F.3d 733, 748-41 (5th Cir. 2015); Ass'n of Private Sector Colleges & Univs. v. Duncan, 681 F.3d 427, 458 (D.C. Cir. 2012); Order Granting Motion to Intervene at 1-2, U.S. House of Representatives v. Price, No. 16-5202 (D.C. Cir. Aug. 1, 2017) (holding the states have standing based on their allegations of harm to their citizens from the termination of CSR payments and the resulting costs likely to be borne by the states in response to the harm). Second, the Administration contends that even if the states have standing to sue in federal court, they haven't sued in the proper federal court. Since most of the plaintiffs in this case have intervened in the D.C. Circuit appeal, the Administration contends it is not appropriate for the states to pursue a separate action in this Court. While it's true that the usual rule is for federal district courts to refuse to adjudicate matters where a case with significant overlap is already being adjudicated in another federal court, that rule is subject to many exceptions. Whether to allow the second suit to proceed is a matter of judicial discretion, particularly in extraordinary cases. See Church of Scientology of California v. U.S. Dep't of Army, 611 F.2d 738, 749-50 (9th Cir. 1980), overruled on other grounds, Animal Legal Defense Fund v. U.S. Food & Drug Admin., 836 F.3d 987 (9th Cir. 2016) (en banc); see also Alltrade, Inc. v. Uniweld Products, Inc., 946 F.2d 622, 628 (9th Cir. 1991); EEOC v. Univ. of Pennsylvania, 850 F.2d 969, 977 (3d Cir. 1988). This is not a situation where a plaintiff sued in one court, didn't like how it was going, and then tried to sue in another court. See, e.g., Padilla v. Willner, No. 15-cv-04866-JST, 2016 WL 860948, at *5 (N.D. Cal. Mar. 7, 2016). Nor is it a situation where a plaintiff sued in one court only to see the defendant respond by suing in a different forum that the defendant found 9 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 10 of 29 more attractive. See, e.g., Intersearch Worldwide, Ltd. v. Intersearch Grp., Inc., 544 F. Supp. 2d 949, 955-64 (N.D. Cal. 2008). The states were not parties to the D.C. litigation until they moved to intervene in the appeal to protect their interests. Moreover, given the states' alleged need for emergency relief, it was not merely justifiable to seek that relief in a different forum; it was prudent. The D.C. case is on appeal, and currently stayed, so it's not clear how quickly the states could get their request for emergency relief heard in D.C. What's more, there are serious questions about whether the D.C. Circuit has jurisdiction in the appeal. The Obama Administration argued, and the Trump Administration continues to argue, that the House of Representatives never had standing to bring the lawsuit challenging the CSR payments in the first place. Brief for Appellants at 19-38, U.S. House of Representatives v. Burwell, No. 16-5202 (D.C. Cir. Oct. 24, 2016); Defs.' Opp'n at 8 n.5, Dkt. No. 35. If that's correct (and could it really be wrong if both Administrations agree on it?), it means Judge Collyer lacked jurisdiction to issue the ruling against the Obama Administration. This, in turn, likely means the D.C. Circuit lacks jurisdiction to do anything other than dismiss the appeal (or remand to the district court with instructions to dismiss the case for lack of standing). See Steel Co. v. Citizens for a Better Env't, 523 U.S. 83, 94 (1998); see also, e.g., Bender v. Williamsport Area Sch. Dist., 475 U.S. 534, 539-49 (1986); Ervine v. Desert View Regional Medical Center Holdings, LLC, 753 F.3d 862, 866-71 (9th Cir. 2014). III. "A plaintiff seeking a preliminary injunction must establish that he is likely to succeed on the merits, that he is likely to suffer irreparable harm in the absence of preliminary relief, that the balance of equities tips in his favor, and that an injunction is in the public interest." Winter v. Natural Resources Defense Council, Inc., 555 U.S. 7, 20 (2008). A court may grant a preliminary injunction even if a plaintiff only shows that there are "serious questions going to the merits"—a lesser showing than likelihood of success on the merits, if the balance of hardships "tips sharply in the plaintiff's favor," the plaintiff is likely to suffer irreparable harm, and the injunction is in the public interest. Alliance for the Wild Rockies v. Cottrell, 632 F.3d 1127, 1135 10 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 11 of 29 (9th Cir. 2011). When the government is a party, the public interest and balance of hardships analyses often merge. Drakes Bay Oyster Co. v. Jewell, 747 F.3d 1073, 1092 (9th Cir. 2014). A. First the merits. On the legal question presented – whether Congress has appropriated money for the CSR payments – both sides have reasonable arguments. However, with the important caveats that the Court has only been given a few days to study this complex matter and the states may not have fully developed all arguments, it initially appears the Administration has the stronger legal position. 8 To understand both sides' arguments, it's important to know how laws get put on the books. When statutory provisions from new laws like the Affordable Care Act are incorporated into the U.S. Code (the official compilation of all federal laws), they are considered "codified." The U.S. Code is divided into different parts based on subject area, such as the Internal Revenue Code and the Public Health and Welfare Code. The numbering of the sections of bills when they are first passed by Congress do not match the numbering of the sections of the U.S. Code where they are ultimately codified. In other words, when Congress votes on a bill, that bill has many sections. But language from different sections of the bill is often inserted into different parts of the U.S. Code, based on what the particular section seeks to accomplish. The Affordable Care Act contains clear language making a permanent appropriation for the premium tax credits. Section 1401 of the Act established the premium tax credits, and the language of section 1401 was codified in the Internal Revenue Code – specifically, in 26 U.S.C. § 36B. Section 36B provides that lower-income people buying insurance on an exchange "shall" 8 The states raise claims under the Administrative Procedure Act, the Take Care Clause of the U.S. Constitution, and the Declaratory Judgment Act. Complaint at 22-23. Success on any of these claims almost certainly depends on whether Congress appropriated money to fund the CSR payments, because the Court can only award the relief the states seek if money was appropriated for this purpose. See, e.g., Office of Personnel Management v. Richmond, 496 U.S. 414, 424-25 (1990); Reeside v. Walker, 52 U.S. (11 How.) 272, 291 (1850); Rochester Pure Waters Dist. v. EPA, 960 F.2d 180, 184 (D.C. Cir. 1992). 11 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 12 of 29 receive the "premium assistance credit." Id. That is how, to use federal budgeting parlance, the tax credits were "authorized." But this language does not appropriate the money for the credits. The Affordable Care Act accomplished the appropriation by amending a different statute, namely 31 U.S.C. § 1324. This statute is contained in the portion of the U.S. Code titled "Money and Finance," and section 1324 is in fact titled "refund of internal revenue collections." Subsection 1324(a) makes a permanent appropriation for tax refunds, stating that "[n]ecessary amounts are appropriated to the Secretary of the Treasury for refunding internal revenue collections as provided by law." Then, subsection 1324(b) imposes limits on the tax refunds for which the permanent appropriation is made. It states that the executive branch may "only" make disbursements under section 1324 for: (1) individual tax refunds; and (2) "refunds due from" various provisions of the Internal Revenue Code, including (after passage of the Affordable Care Act) section 36B. Therefore, section 1324 clearly contains a permanent appropriation for the premium tax credit program codified at 26 U.S.C. § 36B. This clarity is in contrast to the language in the Act involving cost-sharing reductions. As mentioned in the preceding paragraph, section 1401 of the Affordable Care Act created the tax credits and was codified at 26 U.S.C. § 36B – which is part of the Internal Revenue Code. Section 1402 of the Affordable Care Act created the cost-sharing reduction program. Unlike section 1401's premium tax credits, section 1402's cost-sharing reduction program is not codified in section 36B of the Internal Revenue Code; rather it is codified in the Public Health and Welfare Code, at 42 U.S.C. § 18071. The cost-sharing reduction program requires the insurance companies to lower the amount consumers must pay out of pocket, and in turn requires the federal government to pay the companies for the reductions. 42 U.S.C. § 18071(c)(3)(A) (federal government "shall make periodic and timely payments to the [insurance company] equal to the value of the reductions" (emphasis added)). This is how the Affordable Care Act "authorized" the cost-sharing reduction program and the CSR payments to the insurers. But there is no explicit language regarding appropriations. While the Act added section 36B of the Internal Revenue Code to the permanent appropriations statute for tax refunds (namely, 31 12 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 13 of 29 U.S.C. § 1324) the Act did not add section 18071 of the Public Health and Welfare Code to that same appropriations statute for tax refunds. Nor does the Act appear to have included any other explicit language making a permanent appropriation for the CSR payments to insurers. This may suggest that Congress needed to make annual appropriations before the executive branch could make the CSR payments, and that the Obama Administration (along with the Trump Administration for the first half of 2017) acted unconstitutionally by making the payments every month since 2014. See U.S. Const. art. I, § 9, cl. 7 ("No Money shall be drawn from the Treasury, but in Consequence of Appropriations made by Law . . . ."); see also U.S. House of Representatives, 185 F. Supp. 3d at 185. The response by the states is that the language of 31 U.S.C. § 1324, which makes a permanent appropriation for the premium tax credits established in 26 U.S.C. § 36B, impliedly includes a permanent appropriation for the CSR payments established by 42 U.S.C. § 18071. Specifically, the states argue that: (i) 31 U.S.C. § 1324 appropriates money for "refunds due from" 26 U.S.C. § 36B; (ii) the cost-sharing reductions from 42 U.S.C. § 18071 are closely coordinated with the premium tax credits throughout the statute; (iii) a person cannot receive the cost-sharing reductions unless she also gets the tax credits; and therefore (iv) the cost-sharing reductions from 42 U.S.C. § 18071 should be considered "refunds due from" section 36B within the meaning of section 1324. This argument is based on the Supreme Court's ruling in King v. Burwell, which also involved the Affordable Care Act. There, the Court considered language providing that tax credits would go to people who purchased insurance through "an Exchange established by the State." King, 135 S. Ct. at 2487. This language seemed unambiguous when read in isolation: premium tax credits were available for lower-income people who purchased insurance through an exchange established by a state, but not for people who purchased insurance through an exchange established by the federal government. But the Court held that the Act did, in fact, provide premium tax credits for lower-income people who bought insurance through federal exchanges. Id. at 2495-96. 13 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 14 of 29 There were two steps in the Court's analysis. First, the Court determined that although the pertinent language seemed unambiguous when read in isolation, it became ambiguous upon reading other parts of the Act. Among other things, the Act required all exchanges (state and federal) to complete certain tasks relating to the premium tax credits. "If tax credits were not available on Federal Exchanges," the Court explained, "these provisions would make little sense." Id. at 2492. Second, after concluding that the phrase "an Exchange established by the State" was ambiguous in light of the surrounding statutory language, the Court set out to resolve the ambiguity by examining the purposes of the Affordable Care Act. That part was easy, because as discussed at the outset of this ruling, there are three pillars to the Act: preventing insurers from refusing coverage or charging more based on a person's health status, requiring people to get insurance, and making it affordable to purchase insurance on the exchanges. The failure to provide tax credits to lower-income people in places with federal exchanges would have removed one of those pillars, causing the whole health care reform project designed by Congress to come crumbling down. Id. at 2495-96. Thus, the Court resolved the ambiguity in the pertinent language by interpreting it to provide tax credits for insurance purchased on all exchanges, state and federal. In this case, the states present some good arguments relating to the second part of the King v. Burwell analysis. To be sure, the absence of money for CSR payments does not seem to be causing health care reform to come crumbling down, as discussed in the next section. Nonetheless, the absence of a permanent appropriation for these payments may be in significant tension with congressional purpose. For example, as argued most persuasively by the amicus brief from America's Health Insurance Plans, the absence of a permanent appropriation seems odd from a timing standpoint. Insurance companies must work with the states to set their rates for the coming year well in advance (for example, insurers were expected to set their 2018 rates early in 2017). If CSR payments are subject to the vagaries of the annual appropriations process (which Congress often does not complete until late in the year), insurance companies cannot 14 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 15 of 29 reasonably predict how much it will cost to provide insurance on the exchanges. This uncertainty could make insurance companies less likely to offer coverage on the exchanges, leaving consumers with fewer options (or, far worse, no options) in a given geographic region. 9 In addition, the two subsidies that form one pillar of health care reform – the tax credits and the cost-sharing reductions – fit hand in glove: the tax credits allow lower-income people to buy health coverage, and the cost-sharing reductions allow people to actually use this coverage. It's not clear why Congress would have intended more certainty for one type of expenditure than the other. This is particularly true where the Act establishes the same basic procedure for processing the subsidies. The federal government estimates the amount of tax credits and costsharing reductions to which a person is entitled and provides that amount in advance to the insurance company, allowing the insurance company to provide cheaper coverage to lowerincome people who get insurance on the exchanges. 10 See 42 U.S.C. § 18082. 9 On the other hand, perhaps one response is that this is not the first time Congress has imposed mandatory spending requirements – important ones – on the executive branch, while leaving appropriations for those spending requirements to the annual appropriations process. See, e.g., 42 U.S.C. § 1396-1 (authorizing annual appropriations for Medicaid grants to states pursuant to Title XIX of the Social Security Act); Defs.' Opp'n at 22-23, Dkt. No. 35 (listing other mandatory spending programs funded by annual appropriations); see also U.S. House of Representatives, 185 F. Supp. 3d at 185. 10 But perhaps the response here is that the tax credits are far more central to the Act's health care reform project, so Congress took extra care to protect funding for those. After all, as discussed earlier, the tax credits represent a much larger investment of money by the federal government – $32 billion in 2016 compared to $7 billion for the cost-sharing reductions. Congressional Budget Office, Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2016 to 2026 at 31, tbl. 2 (2016), https://www.cbo.gov/sites/default/files/114th-congress-20152016/reports/51385-healthinsurancebaselineonecol.pdf [https://perma.cc/M3S7-8X53]. They benefit more people, as well as a wider range of the population (for the tax credits, people whose incomes put them between 100% and 400% of the federal poverty level, and for the cost-sharing reductions, people whose incomes put them between 100% and 250% of the federal poverty level). 2017 Marketplace Plan Selections with Financial Assistance, Kaiser Family Foundation, https://www.kff.org/health-reform/state-indicator/2017-marketplace-plan-selections-byfinancial-assistance-status [https://perma.cc/VX6G-Q47Z]. It also bears recalling that the absence of funding for CSR payments does not prevent lower-income people from receiving that subsidy. It means only that the insurance companies pay for it, rather than the federal government. And as discussed in the next section, the states have devised a way for insurance companies to recoup those costs, apparently while also avoiding harm to (and instead 15 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 16 of 29 But recall that the Court in King v. Burwell, before resolving a statutory ambiguity by looking to the purpose of the Affordable Care Act, first had to conclude that a provision which seemed clear in isolation was actually ambiguous in light of other language in the Act. It's this first part of the analysis that gives the states a tougher challenge. Although the states emphasize that the premium tax credits and cost-sharing reductions are mentioned together no fewer than 45 times in the Affordable Care Act, it's not clear that this feature of the statute supports their proposed reading of it. Repeatedly referring to the two programs by their separate names suggests Congress considered them distinct, if undoubtedly related. And the statute often recites not just the names of these two programs, but the different statutory provisions that created them. For instance, in the advance payment provision, which is central to the states' argument, the statute refers to "the premium tax credit allowable under section 36B of Title 26 and the cost-sharing reductions under section 18071 of this title." 42 U.S.C. § 18082(a)(1); see also, e.g., id. § 300gg-4(l)(3)(A)(ii) ("credits under section 36B of Title 26 or cost-sharing assistance under section 18071 of this title"); id. § 18031(i)(3)(B) ("premium tax credits under section 36B of Title 26 and cost-sharing reductions under section 18071 of this title"). That Congress so often identified each reform by its location in one title of the U.S. Code or the other suggests that Congress was cognizant of the different way in which each reform fit into the statutory scheme. In other words, the language relied on by the states may further suggest that Congress did not intend the reference to section 36B in the permanent appropriation provision to encompass the CSR payments codified in an altogether different place. The states also point to language prohibiting the use of either premium tax credits or CSR payments for abortion services. See id. § 18023(b)(2)(A). This language achieves the same purpose as the Hyde Amendment, which is the amendment routinely enacted as part of annual appropriations legislation that likewise bars the use of federal funds for abortion services. See benefitting) lower-income people who buy insurance on the exchange. 16 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 17 of 29 Dalton v. Little Rock Family Planning Services, 516 U.S. 474, 475 n.1 (1996) (per curiam). Including a similar restriction in the Affordable Care Act, the states contend, would be redundant unless the CSR payments were exempted from the annual appropriations process. Perhaps that's right. On the other hand, there appears to be no requirement that Congress incorporate the Hyde Amendment into its appropriations legislation every year. So perhaps there is an argument that Congress, by including a similar restriction in the Affordable Care Act, simply intended to ensure that the federal money associated with either reform not be used to pay for abortion services regardless of whether Congress chose to enact the Hyde Amendment in any given year. See id. at 477-78 (acknowledging "the changeable nature of spending bills in general, and the Hyde Amendment in particular" (citation omitted)). The states also argue that, had Congress intended for the CSR payments to be funded through annual appropriations, it would have included a provision saying so. For instance, Congress could have included an "authorization of appropriations" provision when it set up the cost-sharing program, as it did in several other provisions of the Affordable Care Act. See, e.g., Pub. L. No. 111-148, § 3511, 124 Stat. 119, 538 (2010); id. § 4003(a)(7), 124 Stat. at 543; id. § 5306(a), 124 Stat. at 626-67. In other words, in the states' view, because the Act included language authorizing annual appropriations for other programs implementing health care reform, the omission of such language in the CSR payment provisions suggests that Congress funded the CSR payments through the permanent appropriation in 31 U.S.C. § 1324(b). That might be right, but it's not a necessary conclusion. At oral argument, counsel for the states referred to other, unspecified programs created by the Affordable Care Act that didn't include specific authorization language but for which there may also be no permanent appropriation. Moreover, apparently such language is not needed to authorize an annual appropriation, and annual appropriations appear to be the default way in which Congress provides funds. See U.S. Government Accounting Office, GAO-04-261SP, Principles of Federal Appropriations Law (Vol. 1) 2-13, 2-41 (3d ed. 2004); Civil Rights Commission, 71 Comp. Gen. 378 (1992). Looming over this whole discussion is the fact that the parties are disputing the meaning 17 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 18 of 29 of an appropriations statute, not just any statute. Congress has established certain rules regarding appropriations, including that "[a] law may be construed to make an appropriation out of the Treasury . . . only if the law specifically states that an appropriation is made . . . ." 31 U.S.C. § 1301(d). Perhaps the clear-statement rule announced in this provision is of limited relevance here, since it is undisputed that the appropriations provision at issue, 31 U.S.C. § 1324, makes a permanent appropriation, meaning that the disagreement concerns the scope of that appropriation, not its existence. Counsel for the Administration appeared to concede this point at oral argument. But even putting section 1301 aside, the role of the Appropriations Clause in enforcing the constitutional separation of powers provides reason for caution in adopting a reading of an appropriations statute broader than the one most obviously provided by the text. See, e.g., U.S. Dep't of Navy v. Federal Labor Relations Authority, 665 F.3d 1339, 1347 (D.C. Cir. 2012). 11 In sum, the Affordable Care Act requires the federal government to pay insurance companies to cover the cost-sharing reductions. The federal government is failing to meet that obligation. If there was no permanent appropriation in the Act, Congress is to blame for the 11 There are a couple of arguments the states and their allies do not make. Perhaps there is good reason for this, so the Court mentions them only as an indication of the extent to which further briefing and research would be helpful before a definitive ruling on the merits. First, although the states contend Congress affirmatively intended to make a permanent appropriation through section 36B while the Administration contends Congress affirmatively intended to leave CSR payments to the annual appropriations process, it's conceivable that Congress simply forgot to include permanent appropriations language for the payments. Certainly if CSR payments are as integral to the statutory scheme as the states claim (and as the Obama Administration argued) then the omission of any appropriations-related language may have been unintentional. Cf. Lamie v. U.S. Trustee, 540 U.S. 526, 538 (2004); Heppner v. Alyeska Pipeline Serv. Co., 665 F.2d 868, 872 (9th Cir. 1981). There are, after all, numerous apparent errors in the statutory text. See, e.g., King, 135 S. Ct. at 2942 (noting that the Affordable Care Act created "three separate Section 1563s"). The parties have not discussed what the legal implications would be if Congress had intended, but simply forgotten, to make the appropriation. Nor do the states explore, as an alternative argument, the possibility that funds for CSR payments could be drawn from a general programmatic appropriation or other source. Cf. Department of Health and Human Services – Risk Corridors Program, B-325630, 2014 WL 4825237 (Comp. Gen. Sept. 30, 2014). 18 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 19 of 29 failure, because it has not been making annual appropriations for CSR payments. The Administration cannot fix Congress's error, because the Constitution prevents the Administration from making payments on its own. In contrast, if the Act created a permanent appropriation, the Administration is legally at fault for the federal government's failure to meet its obligation under the Act to make CSR payments. On the merits, it's a close and complicated question, even if the Administration may seem to have the better argument at this stage. B. The remaining three preliminary injunction inquiries (irreparable harm to the plaintiffs, the balance of hardships, and the public interest) overlap significantly, so they are discussed together in this section. On the issue of harm to the plaintiffs themselves (namely, the states), the Administration's decision to terminate the CSR payments certainly will cause some degree of direct and irreparable injury. As already discussed in Section II, the states are incurring significant administrative costs in responding to the termination of the payments, and there likely is no way to remedy that when the case is over. But in a case like this, where so much of the harm is alleged to be inflicted on society, and particularly on lower-income residents who need health coverage, the crucial question is whether the absence of a preliminary injunction would harm the public and impede the objectives of health care reform. The Affordable Care Act is the law of the land, and its goal is to provide meaningful and affordable health coverage to people who don't get it through their jobs. Any significant interference with that goal not clearly permitted by law is a major harm that would justify an injunction. But it bears repeating that the only question presented by this motion is whether the Court should require the Administration to make the CSR payments for a few months – that is, until this Court can reach a final decision on the case, likely in early 2018. Therefore, allegations by the states about harms that loom further on the horizon – say, in 2019 or beyond – are not particularly relevant at the moment, because those harms can likely be addressed at the end of the case, if the states are indeed able to prevail on the merits. What matters for this motion is how people will be affected in 2017 and 2018 without a preliminary injunction. 19 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 20 of 29 In that regard, it appears that because of the measures taken by the states in anticipation of a decision by the Administration to terminate CSR payments, the large majority of people who purchase insurance on exchanges throughout the country will either benefit or be unharmed. In particular, many lower-income people stand to benefit. To explain this requires a somewhat detailed discussion of how things work on the exchanges. There are four basic levels of health insurance plans available on the exchanges: bronze plans, silver plans, gold plans, and platinum plans. As the names imply, the levels vary in quality, with the bronze plans estimated to cover 60% of a person's health care costs, the silver plans 70%, the gold plans 80%, and the platinum plans 90%. See 42 U.S.C. § 18022(d). If you meet the income requirements (that is, if your income puts you between 100% and 400% of the federal poverty level) you qualify for the premium tax credits, and you can use those tax credits to help purchase insurance on the exchanges. As mentioned earlier, you don't need to front the full premium payments and wait for a tax credit the following year. Under the Affordable Care Act, the federal government estimates your tax credit for next year and gives the insurance company the money, so that you get an upfront discount on premiums based on your tax credit. See 42 U.S.C. § 18082(c)(2)(A). The calculation of the tax credit is complicated, but for this discussion what's important is that the amount is based on the cost of the second-cheapest silver plan available on the exchange in your geographic area, and then adjusted based on your income (that is, based on where you fall on the spectrum between 100% and 400% of the federal poverty level). So, if premiums for the second-cheapest silver plan in your area go up, the amount of your tax credit will go up by a corresponding amount. See 26 U.S.C. § 36B. With respect to cost-sharing subsidies, the Affordable Care Act only requires insurers to offer them for silver plans. 42 U.S.C. § 18071(b)(1). This often makes silver plans the most attractive for lower-income people who qualify for both tax credits and cost-sharing subsidies (people who earn between 100% and 250% of the poverty level). The monthly premiums of the silver plans are relatively low and covered in part by tax credits, and the cost of actually going to 20 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 21 of 29 the doctor is low because of the Act's cost-sharing reductions. 12 With this background, let's rewind to early 2017. Anticipating that the Administration would terminate CSR payments, most states began working with the insurance companies to develop a plan for how to respond. Because the Affordable Care Act requires insurance companies to offer plans with cost-sharing reductions to customers, the federal government's failure to meet its CSR payment obligations meant the insurance companies would be losing that money. So most of the states set out to find ways for the insurance companies to increase premiums for 2018 (with open enrollment beginning in November 2017) in a fashion that would avoid harm to consumers. And the states came up with an idea: allow the insurers to make up the deficiency through premium increases for silver plans only. In other words, allow a relatively large premium increase for silver plans, but no increase for bronze, gold, or platinum plans. 13 As a result, in these states, for everyone between 100% and 400% of the federal poverty level who wishes to purchase insurance on the exchanges, the available tax credits rise substantially. Not just for people who purchase the silver plans, but for people who purchase other plans too. 12 For example, when a person earning between 100% and 150% percent of the federal poverty level buys a silver plan, that silver plan is estimated to cover 94% of the person's health care costs because of the cost-sharing reduction subsidies. See 42 U.S.C. § 18071(c)(2)(A). Recall that a silver plan without cost-sharing subsidies is designed to cover only 70% of a person's health care costs. By covering 94% of her costs, the silver plan with cost-sharing subsidies provides more insurance than even a platinum plan, which is designed to cover 90% of a person's health care costs. 13 To be precise, premium increases for those other plans were permitted for other reasons, such as to account for changing medical costs and the overall health of plan members, but not to account for the loss of CSR payments from the federal government. 21 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 22 of 29 As an example, take a 50-year-old single person at 300% of the poverty level who lives in Santa Clara County (specifically, San Jose). The chart below shows the effect for her, in 2018, of California's response to the Administration's termination of the CSR payments. For 2017, her available tax credit was $284. In 2018, because of the silver plan premium increases, her tax credit will be $393. As a result, the area's most popular bronze plan would have cost her $134 per month in 2017, but the same bronze plan, with her increased tax credit, will cost her $53 per month in 2018. The area's most popular silver plan would have cost her $292 per month in 2017, while the same plan will cost her only a dollar more per month in 2018. And take a look at the gold plan. The area's most popular gold plan would have cost her $354 per month in 2017, but it will cost her just $267 per month in 2018. This means that if she had the silver plan in 2017, she can switch to the gold plan in 2018, paying $25 less per month for higher quality care. 22 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 23 of 29 These figures were taken directly from the website for Covered California, the state entity that operates the exchanges and is largely responsible for administering the Affordable Care Act exchanges in the state. The chart is reproduced at Appendix A to this opinion, backed up by the screenshots from the queries made on the Covered California website. Incidentally, in these screenshots the consumer is not told what the premium price would be absent the tax credit, so there's nothing to scare the customer away – nothing to mislead her into thinking the premiums are higher than they actually will be for her. Appendices B through E contain charts and screenshots for people in other California cities and with different income levels. Although results vary somewhat from place to place, the pattern is largely similar: for lower-income people who purchase insurance on the exchange, the elimination of the CSR payments will not increase premiums for the silver plans, but it will cause premiums for the other plans to go down. No wonder that back in January 2017, economists hired by the State of California estimated that the state's response to the anticipated termination of CSR payments would result in 20,000 more people buying health care in California in 2018. 14 Even before the Administration announced its decision, 38 states accounted for the possible termination of CSR payments in setting their 2018 premium rates. 15 And now that the 14 Wesley Yin & Richard Domurat, Covered California, Evaluating the Potential Consequences of Terminating Direct Federal Cost-Sharing Reduction (CSR) Funding (2017), https://www.coveredca.com/news/pdfs/CoveredCA_Consequences_of_Terminating_CSR.pdf [https://perma.cc/ZB9D-XVVL]. 15 See Decl. of Jeff Wu at 5, Dkt. No. 35-5; see also, e.g., Part II Rate Increase Justification, Mountain Health CO-OP, https://doi.idaho.gov/DisplayPDF?Cat=consumer&ID=2018_MHC_Indiv&Type=pdf [https://perma.cc/T6MN-PC4Z]; Insurance Shopping A Challenge for Connecticut Consumers, New Haven Register (Oct. 20, 2017), http://www.nhregister.com/news/article/Insuranceshopping-a-challenge-for-Connecticut-12293891.php [https://perma.cc/VH65-BYWD]; Steve Sinovic, Subsidy Cut Already Priced Into Premiums, Albuquerque Journal (Oct. 19, 2017), https://www.abqjournal.com/1080093/subsidy-cut-already-priced-into-premiums.html [https://perma.cc/9HKF-KP26]; Margot Sanger-Katz, Trump's Attack on Insurer 'Gravy Train' Could Actually Help a Lot of Consumers, New York Times (Oct. 18, 2017), https://www.nytimes.com/2017/10/18/upshot/trumps-attack-on-insurer-gravy-train-couldactually-help-a-lot-of-consumers.html; Kristen Schorsch, How Team Rauner Hustled To Protect Obamacare from Trump, Crain's Chicago Business (Oct. 17, 2017), http://www.chicagobusiness.com/article/20171017/NEWS03/171019869/how-team-raunerhustled-to-protect-obamacare-from-trump [https://perma.cc/26GG-P9X4]; Louise Norris, Nevada's Health Insurance Marketplace: History and News of the State's Exchange, 23 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 24 of 29 announcement has been made, even more states are adopting a strategy like California's, including states that are plaintiffs in this lawsuit but had not already put a plan in place. 16 Recall that roughly 85% of people who purchase insurance on exchanges throughout the country qualify for tax credits, and recall that roughly 12 million people purchase insurance on exchanges, so the improvements described above have the potential to benefit millions of lower-income people. What about a person who does not qualify for tax credits? This question is more complicated. In the states that responded to the Administration's decision by permitting premium increases for only silver plans, this higher-income person can buy a bronze, gold, or platinum plan for the same price they'd otherwise have been required to pay. 17 And in at least a HealthInsurance.org (Oct. 5, 2017), https://www.healthinsurance.org/nevada-state-healthinsurance-exchange/#CSR [https://perma.cc/W4E3-XUST]. 16 See Decl. of Jeff Wu at 5-6, Dkt. No. 35-5; Meredith Cohn, Maryland Officials Consider Higher Obamacare Rates After Federal Subsidies Cut, Baltimore Sun (Oct. 23, 2017), http://www.baltimoresun.com/health/bs-hs-new-obamacare-rates-20171023-story.html; Holly K. Michels, Health Insurance Companies Able To Raise Rates, Continue Selling on Exchange, Independent Record (Oct. 19, 2017), http://helenair.com/news/politics/state/health-insurancecompanies-able-to-raise-rates-continue-selling-on/article_f2e30986-d61e-5b15-8fdc73e8448ee1e4.html [https://perma.cc/C278-9RNA]; Press Release, Pennsylvania Pressroom, Acting Insurance Commissioner Announces Approved 2018 Individual and Small Group Rates, Highlights Opportunities To Lessen Impact of Trump Administration Actions on Pennsylvania Consumers (Oct. 16, 2017), http://www.media.pa.gov/Pages/Insurance-Details.aspx?newsid=278 [https://perma.cc/HZ8P-2VLE]; Letter from Mike Kreidler, Insurance Commissioner, State of Washington, to Plan Year 2018 Individual Market Health Plan Issuers (Oct. 16, 2017), https://www.insurance.wa.gov/sites/default/files/documents/Kreidler-letter-to-issuers-CSR101617.pdf [https://perma.cc/Q5W9-SBG9]; Press Release, Oregon Division of Financial Regulation, State Announcement Regarding Trump Administration Discontinuation of CostSharing Reduction Payments, Oregon Division of Financial Regulation (Oct. 13, 2017), http://dfr.oregon.gov/news/Pages/20171013-trump-payment-reduction.aspx [https://perma.cc/3HTP-RU58]; Liz Ruskin, Premera To Bump Up Premium To Cover Trump Cut, Alaska Public Media (Oct. 13, 2017), http://www.alaskapublic.org/2017/10/13/premera-tobump-up-premium-to-cover-trump-cut [https://perma.cc/T4G8-TNCF]. 17 See Decl. of Jeff Wu at 7-8, Dkt. No. 35-5; see also, e.g., Press Release, Oregon Division of Financial Regulation, State Announcement Regarding Trump Administration Discontinuation of Cost-Sharing Reduction Payments (Oct. 13, 2017), http://dfr.oregon.gov/news/Pages/20171013trump-payment-reduction.aspx [https://perma.cc/3HTP-RU58]; Press Release, Pennsylvania Pressroom, Acting Insurance Commissioner Announces Approved 2018 Individual and Small Group Rates, Highlights Opportunities To Lessen Impact of Trump Administration Actions on Pennsylvania Consumers (Oct. 16, 2017), http://www.media.pa.gov/Pages/InsuranceDetails.aspx?newsid=278 [https://perma.cc/HZ8P-2VLE]; Press Release, Covered California, Covered California Keeps Premiums Stable by Adding Cost-Sharing Reduction Surcharge Only to Silver Plans to Limit Consumer Impact 2 (Oct. 11, 2017), https://www.calhospital.org/sites/main/files/file-attachments/10-11-17_-_coveredca__csr_surcharge.pdf [https://perma.cc/4P73-BPCU]. 24 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 25 of 29 subset of the states described above, including California, this person can also buy a silver plan without paying more. Although the monthly premiums for silver plans sold on the exchange will increase, insurers and regulators in some states have also developed a set of comparable plans available off the exchange. The monthly premiums for these "off-exchange silver" plans will not increase in response to the CSR increases, because unlike on-exchange silver plans, these plans will not provide cost-sharing reductions. 18 So someone with a higher income who wants to purchase a silver plan need not lose money, but to do so he will have to purchase that policy from outside the exchange. For all these reasons, Covered California issued a press release the day before the Administration publicly announced its decision to terminate CSR payments. In the press release, Covered California proclaimed: "because the surcharge [that is, the increase attributable to the Administration's decision] will only be applied to Silver-tier plans, nearly four out of five consumers will see their premiums stay the same or decrease, since the amount of financial help they receive will also rise." The press release later says: "In addition, Covered California consumers with Silver plans who do not receive financial help to pay their premium can also avoid paying the surcharge by switching to a different metal tier or buying near-identical Silver coverage directly from a health insurance company." 19 But apparently, even in California, one out of five consumers will see premiums increase because of the termination of CSR payments. Though the states certainly haven't offered a concrete explanation for why some people might see increased premiums, here are some possibilities. Some people whose income is not low enough to receive tax credits will likely enroll or re-enroll in silver plans sold on the exchange because they do not know they can purchase a comparable but more affordable plan outside the exchange. Others may see their 18 19 See supra note 17. Press Release, Covered California, Covered California Keeps Premiums Stable by Adding Cost-Sharing Reduction Surcharge Only to Silver Plans to Limit Consumer Impact 1-2 (Oct. 11, 2017), https://www.calhospital.org/sites/main/files/file-attachments/10-11-17_-_coveredca__csr_surcharge.pdf [https://perma.cc/4P73-BPCU]. 25 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 26 of 29 rates increase because the price of the silver plan they purchased increased by more than the price of the second cheapest silver plan in their region (the plan that matters for purposes of measuring tax credits). In any event, the Covered California press release says that about half those people "will see increases of less than $25 per month." 20 Presumably, if the payments were restored, premiums for the silver plans would need to be reduced, because the insurance companies would no longer need to increase them to recover the value of the lost CSR payments. But as the above discussion shows, such a remedy would likely cause millions of lower-income people across the country who purchase insurance on the exchanges to be worse off than if today's status quo is preserved. Their tax credits would go down, the bottom-line cost of purchasing bronze and gold plans would go up, and the bottomline cost of purchasing silver plans wouldn't go down. When counsel for the State of California was confronted at oral argument with the fact that the relief sought by the states could cause this harm, he responded by suggesting that perhaps the Court could order the Administration to resume the CSR payments even while the states continue to allow the insurance companies to charge higher premiums on the exchanges, with the idea that the numbers would reconciled later, through some unexplained process. In other words, allow the insurance companies to collect double payments in 2018. This argument does not even merit a response. But it does raise the question: why, in light of this discussion, have all these Attorneys General rushed to court seeking an emergency ruling against President Trump? The primary reason offered by the states, and one they repeat over and over, is that premiums will go up for millions of people. But as already discussed, they are only able to make that argument sound compelling by omitting the fact that the premium increases in almost every state will cause tax credits to increase in a corresponding amount, leaving so many people (especially lower-income people) better off or unharmed. To be sure, in the few states that have 20 Id. at 2. 26 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 27 of 29 not responded as most states have, the harm may be greater. But it may not be too late for those states to change course; for example, just two days ago, Maryland apparently finalized its decision to take the California approach. 21 The states also assert that insurance companies will withdraw from the exchanges for 2018 because of the Administration's decision to terminate the CSR payments. But for the most part insurance companies seem to have chosen to work with the states to anticipate the termination rather than withdrawing. And the states don't identify a single company that has withdrawn since the Administration announced its decision 13 days ago, even though open enrollment for 2018 begins just 7 days from now. It's true, as the states note, that Anthem withdrew from some exchanges earlier this year, primarily citing the anticipated termination of CSR payments. But the fact that more insurance companies have not done so suggests perhaps Anthem did not understand that states would devise a way for insurance companies to recoup their costs while avoiding harm to most people and in fact benefitting many. 22 The states repeatedly cite a report from the Congressional Budget Office from August 2017 that predicted that termination of CSR payments would cause the ranks of the uninsured in the United States to increase by 1 million. Two things about that. First, this prediction was based on the assumption that many insurance companies would respond by fleeing the exchanges – something that hasn't happened (at least not for 2018). Second, the Congressional Budget Office report predicts that, starting in 2020, the CSR payment termination will cause the ranks of 21 Morgan Eichensehr, Maryland Seeks To Minimize Higher Obamacare Premiums Following Subsidy Cut, Baltimore Business Journal (Oct. 23, 2017), https://www.bizjournals.com/baltimore /news/2017/10/23/maryland-seeks-to-minimize-higher-obamacare.html [https://perma.cc/23GMVNBN]; see also Decl. of Jeff Wu at 5-6, Dkt. No. 35-5. 22 There may be one very real harm to the insurance companies: although they are recouping the lost CSR payments through 2018 premium increases, it appears those increases don't compensate for the missed payments in October, November, and December of 2017. But financial harm is almost never irreparable harm. Idaho v. Coeur d'Alene Tribe, 794 F.3d 1039, 1046 (9th Cir. 2015). The insurance companies could presumably recover that money once this case is over, if not through a judgment by this Court then through lawsuits brought under the Tucker Act, 28 U.S.C. § 1491(a)(1). See Greenlee County. v. United States, 487 F.3d 871, 877 (Fed. Cir. 2007); Moda Health Plan, Inc. v. United States, 130 Fed. Cl. 436, 441, 450 (2017); see also United States v. Mitchell, 463 U.S. 206, 215-16 (1983). 27 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 28 of 29 the uninsured to decrease by roughly 1 million people. 23 Speaking of which, another harm the states discuss is that the termination of CSR payments will end up costing the federal government more money. They note, correctly, that the widespread increase in silver plan premiums will qualify many people for higher tax credits, and that the increased federal expenditure for tax credits will be far more significant than the decreased federal expenditure for CSR payments. In other words, in their effort to get emergency relief, the states complain that the federal government will be spending more money on health coverage for poor people. The United States suffers from immense inequality of wealth and opportunity. Courts (and in fact, all branches of government) should be reluctant to balance harms or apply laws in ways that exacerbate these inequalities. 24 That's especially true when the statute involved – the Affordable Care Act – reflects a policy judgment that it's unacceptable to allow tens of millions of people (mostly lower-income people) to go uninsured. As the Ninth Circuit has explained in an analogous context, when the tradeoff is between saving money and allowing lower-income people to obtain meaningful health coverage, the balance tips sharply in favor of health coverage. Golden Gate Restaurant Ass'n v. City & County of San Francisco, 512 F.3d 1112, 1125-26 (9th Cir. 2008). Therefore, to the extent the states are truly arguing that it's harmful to bolster health coverage for lower-income people through the use of the progressive tax system, that argument is not well-taken. Finally, the states express concern that the termination of CSR payments will cause confusion among people who shop on the exchanges. In particular, the states argue, the fear of increased premiums may scare consumers from the exchanges. There is likely some truth to that. The Affordable Care Act is complicated, the endeavor of buying insurance on the exchanges is 23 Congressional Budget Office, The Effects of Terminating Payments for Cost-Sharing Reductions 7 (2017), https://www.cbo.gov/system/files/115th-congress-20172018/reports/53009-costsharingreductions.pdf [https://perma.cc/RF6V-TY3C]. 24 See Joseph Fishkin & William E. Forbath, Wealth, Commonwealth, & the Constitution of Opportunity: A Story of Two Traditions, NOMOS (forthcoming), http://ssrn.com/abstract=2620920 [https://perma.cc/RZ2R-4N28]. 28 Case 3:17-cv-05895-VC Document 76 Filed 10/25/17 Page 29 of 29 confusing enough as it is, and the consumers who shop there are not universally sophisticated. See Brief of Amicus Curiae Families USA et al. at 12-19, Dkt. No. 51-2. But if the Administration's decision to terminate the CSR payments added to the confusion, would a court order requiring their resumption alleviate it? Moreover, the states may be overstating their "confusion" argument. As the Appendices illustrate, if you benefit from tax credits and you go shopping for insurance on the Covered California website, you may never even realize that premiums went up. You are only informed of what you have to pay for insurance. And as already discussed, if you're eligible for tax credits, it's highly likely you'll pay the same or less. One last point on the issue of confusion. If the states are so concerned that people will be scared away from the exchanges by the thought of higher premiums, perhaps they should stop yelling about higher premiums. With open enrollment just days away, perhaps the states should focus instead on communicating the message that they have devised a response to the CSR payment termination that will prevent harm to the large majority of people while in fact allowing millions of lower-income people to get a better deal on health insurance in 2018. IV. The motion for a preliminary injunction is denied. A telephonic case management conference will take place on November 21, 2017, at 2:30 p.m. for the purpose of setting a schedule for the full adjudication of the case. IT IS SO ORDERED. Dated: October 25, 2017 ______________________________________ VINCE CHHABRIA United States District Judge 29 Case 3:17-cv-05895-VC Document 76-1 Filed 10/25/17 Page 1 of 11 State Regulators Have Improved Health Care Options for Lower-Income Consumers For a 50 year old living in San Jose who earns 300% of the federal poverty level: Out-of-Pocket Monthly Premiums in 2017 Out-of-Pocket Monthly Premiums in 2018 Consumer Savings Per Month Bronze:† $134 $53 Consumer Saves $81 Silver: $292 $293 Consumer Pays $1 More Consumer Switches to Gold and Saves $25 Gold: $354 $267 Consumer Saves $87 Monthly Tax Credit in 2017 Monthly Tax Credit in 2018 $284 $393 † In Appendices A through E, unless otherwise noted, the plan represented in the chart is the plan that was most often chosen during 2017 open enrollment on Covered California in the region. Covered California, Covered California Open Enrollment Profile, Statewide Cross Tabulations (2017), http://hbex.coveredca.com/data-research/library/CC_Open_Enrollment_Profile_2017.xlsx [https://perma.cc/8VK8-T2P7]. Where two versions of the same plan were sold on the exchange, the version of the plan with lower monthly payments in 2017 was used. Appendix A - 1 of 11 Case 3:17-cv-05895-VC Document 76-1 Filed 10/25/17 Page 2 of 11 camorhelp Find Local Help LOgln Espa?olv i3" "Hum-u? Home FAQs leeChat 1 -787-6921 PREVIEW PLANS TELL US A LITTLE BIT ABOUT YOURSELF. Your information will help us ?nd out ifyou qualify for help paying for health coverage. Coverage Year: 20? 7 What is your Zip Code? 95115 What is y0ur total income per year? *t $35640 How many people are in your household? 1 Enter the age of each person in your household, and tell us ifthey need coverage. Age of Head of Household 50 Needs Coverage? Is anyone in your household pregnant? Yes N0 Is anyone in your household blind or disabled? Yes N0 Back 800 My Result Appendix A - 2 of 11 Case 3:17-cv-05895-VC Document 76-1 Filed 10/25/17 Page 3 of 11 1-800-787-6921 Local Help I Find itli $33352 Application Home FAQs leeChat Ca Logln Espanolv 0 MY OPTIONS Here is what you told us: Zip Code: 95115 Total household income: 535.640 Household members: 1 Age of Head of Household: 50 Years Needs Coverage? Household Includes: Pregnant Blind or Disabled Based on what you told us, here is what you may qualify for: You IlayQudllyior: Lower Premium It looks like you may qualify for a tax credit to lower your premium. More Information Preview Plans These results are only an estimate. You will need to complete an application. Back Appendix A - 3 of 11 cnumnuu Application Home FAQs leeChat 8 plans for 1 adult in ZIP code 95115. Coverage COuld start as early as 01/0152017. Cal for help 1 -800-787-6921 Find premiums displayed have been reduced by your estimated tax credit of 828400 . Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used with a Health Sayings Account Metal Tier Platinum: highest premiums. lowest out-of- pocket costs Gold: higher premiums. lower out of pocket costs Silver: lower premiums. moderate out of pocket (OSIS Bronze: lowest premiums. highest cutof- pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company Any-ham nli-n Sort By Premium (low to high) ADD TO CART l'I E's'm: HMO BRONZE HJO Premium Primary Care ViSits Drugs Yearly Deductic-le Iotal Exoense Estir?r? ate ity Rat ng COMPARE 5104 29 a?ter $284.00 tax credit You pay $75 You pay 100C 3 $6300 $500 gl-i'uy I\z:l Applyi Lower *t?ti VIEW DETAIL ADD TO CART iwsut mummrt II HMO BRONZE H30 Premium Primary Care Vi5its Drugs Yearly Iotal Exoense Estir?r? ate ity Rat ng COMPARE $133 73 a?ter $284.00 tax credit You pay $75 You pay 100C 3 $6300 $500 I\z:l Applyi Lower - i i VIEW DETAIL ADD TO CART blue Ct?) Local Help ADD TO CART 2 ?also: 3?.?le L3 HEMP EPO BRONZE Premium Prmary Care Visns Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE HSA 5110,65 alter $284.001ax credit You pay 40i?ila'v No: .Auu?y: Lower l- it VIEW DETAIL ADD TO CART iwsut mumrmr Eru'uvj '23 HEN: BRONZE Premium Pr:mary Care Visns Generic Drugs Yearly Deduct ble Iota Expense Estimate Oualty Rating COMPARE Appendix A - 4 of 11 HSA HMO 5137,17 alter $284.001ax credit You pay 40? a You pay 40? 2 Sauce l?i'lu'v No: 315534 Lower l- titti VIEW DETAIL ADD TO CART hliie If?) Logln Espa?olv ADD TO CART v33 EPO BRONZE E90 Moothly Premium Primary Care ViSits Generic Drugs Year Deductiole Total Exoense Estin? ate ity Rating COMPARE $11890 a?ter $284.00 tax credit You pay $75 You pay 100c 3 $6300 5 $500 allay Apply-i Lower - VIEW DETAIL ADD TO CART a Health Net? Erenze 43? BRONZE Mo"thly Premium Primary Care ViSits Generic Drugs Year Deductiole Total Exsense Estin? ate ity Rating COMPARE $221 73 a?ler $284.00 tax credit You pay $75 You pay 100c 3 $6300 5 $500 allay Applyi Lower - tit?t VIEW DETAIL cnumnuu Application Home FAQs leeChat 7 plans for 1 adult in ZIP code 95115. Coverage COuld start as early as 01.011201 7. Cal for help 1 -800-787-6921 premiums displayed have been reduced by your estimated tax credit of 828400 . Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used a Health Sayings Account Metal Tier Platinum: highest premiums. lowest out of, pocket costs Gold: higher premiums. lower out of pocket costs Silver: lower premiums. moderate out of pocket (0515 Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company nli-n Sort By Promlum {low to high) we? ADD To CART 2 ll TC- SILVER Premium Primary Care Drugs Yearly Deduetlc-Ie letal Exoense Estrr?ratc rty Rat ng COMPARE 5229 69 a'ter $284.00 tax credit You pay $35 You pay 515 $2500 $250 glv'a',? Lower i i ii? 17 VIEW DETAIL ADD TO CART Anthem Elk-er 7'3 SILVER Premium Prr'nary Care Drugs Yearly Deduetlc-Ie letal txoense Estrn? ate rty Rat no 3340 3S a'ter $284.00 tax credit You pay $35 You pay 515 $2500 $250 glu?ay Nut Average Oual [y Ram-g Ava lat; t: COMPARE VIEW DETAIL ADD TO CART I I in lr'al Local Help ADD To CART "92.2111 till 5 var Til E90. .an lul?E-P SILVER E90 Premium Prmary Care Generic Drugs Yearly Deduct ble Tota Expense Estimate Oualty Hating COMPARE $288.15 alter $284 00 tax credit You pay $35 You pay 515 $2538 5253 l?vla'v Auu?y: Lower l- i' i VIEW DETAIL ADD TO CART blue Ct? 13 SILVER Premium Prmary Care Generic Drugs Yearly Deduct ble Iota Expense Estimate Oualty Hating COMPARE Appendix A - 5 of 11 HMO 5342,25 alter $284.00 tax :rcmt You pay $35 You pay $15 5253?.) $253 l?cluv Auu?y) Averaqe Oual 1y Hating luture VIEW DETAIL Logln Espa?olv ADD To CART . 5 Slice-r SILVER HMO Meethly Premium Primary Care Genenc Drugs Year DeduetIC-le Total Expense Estln" ate rty Rating COMPARE $292 01 a?ter $284.00 tax CIOdll You pay 535 You pay $1 5 $2500 5 $250 allay l\L?l Lower - VIEW DETAIL ADD TO CART (9 Health Net? '5 ver ?3 HEP SILVER Premium Primary Care Genen: Drugs Year Deduetlc-le lotal Exoense Estln? ate rty Rating COMPARE 5387 09 a?ter $284.00 tax CICdll You pay $35 You pay 51 5 $2500 5 $250 alu'a',? Net Average i if? if: VIEW DETAIL cnumnuu Application Home FAQs leeChat 8 plans for 1 adult in ZIP code 95115. Coverage COuld start as early as 01/0152017. Cal for help 1 -800-787-6921 Find premiums displayed have been reduced by your estimated tax credit of 828400 . Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used With a Health Sayings Account Metal Tier Platinum: highest premiums. lowest out-of- pocket costs Gold: higher premiums. lower out of pocket costs Silver: lower premiums. moderate out of pocket (0515 Bronze: lowest premiums. highest cutof- pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company Any-ham nli-n Sort By Premium (low to high) ADD TO CART l'I Gr; 1 BC- GO-D HMO Premium Primary Care ViSits Drugs Yearly Deductic-le Iotal txoense Estir?r? ate ity Rat ng COMPARE $313 47 a?ter $284.00 tax credit You pay $alloy l\t:l Applyi Lower *t?ti VIEW DETAIL ADD TO CART Anthem Go." AP EFO ya:- GOLD Moothly Premium Primary Care ViSits Drugs Yearly Deductic-le letal txoense Estrn? ate ity Rat ng COMPARE EPO $439 17 a'ter $284.00 tax credit You pay $30 You pay $15 $0 $0 kc! Apply: Average it?tt VIEW DETAIL ADD TO CART Local Help ADD TO CART 2 . i PERMANENTE G-JIC E3 HMO Ci; 'i'su'ti" .0 GOLD Premium Prmary Care Visns Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE 5353,90 alter $284.001ax credit You pay $30 You pay 815 SC SC i?ila'v .Auu?y: Averaqe titti VIEW DETAIL ADD TO CART blue Golc .53 GOLD Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE >l NO 547567 alter $284.001ax credit You pay $30 You pay 315 SC SC i?cla'v Auu?y) Averaqe Oual 1y Hating luture VIEW DETAIL ADD TO CART 2 id'- If" IEil Appendix A - 6 of 11 Logln Espa?olv ADD TO CART . . PERMANTNTE Gt; '1 Bl} GO-D HMO Moothly Premium Primary Care ViSits Generic Drugs Year Deductiole Total Exoense Estin? ate ity Rating COMPARE $383 60 a?ter $284.00 tax credit You pay 530 You pay $1 5 $0 SO allay Apply-i Average VIEW DETAIL ADD TO CART Anthem 53? Bin-(Erna Gr; 11 GO-D HMO Premium Primary Care ViSits Generic Drugs Year Deductic-le lotal Expense Estirr ate ity Rating COMPARE 8480 09 a?ter $284.00 tax credit You pay $Net Applyi Higher O"e Opal ty Qati?ig Ava Ian VIEW DETAIL Case 3:17-cv-05895-VC Document 76-1 Filed 10/25/17 Page 7 of 11 camorhelp Find Local Help LOgln Espa?olv i3" "Hum-u? Home FAQs leeChat 1 -787-6921 PREVIEW PLANS TELL US A LITTLE BIT ABOUT YOURSELF. Your information will help us ?nd out ifyou qualify for help paying for health coverage. Coverage Year: 20? 8 What is your Zip Code? 95115 What is y0ur total income per year? *t $36180 How many people are in your household? 1 Enter the age of each person in your household, and tell us ifthey need coverage. Age of Head of Household 50 Needs Coverage? Is anyone in your household pregnant? Yes N0 Is anyone in your household blind or disabled? Yes N0 Back 800 My Result Appendix A - 7 of 11 Case 3:17-cv-05895-VC Document 76-1 Filed 10/25/17 Page 8 of 11 1-800-787-6921 Local Help I Find itli $33352 Application Home FAQs leeChat Ca Logln Espanolv 0 MY OPTIONS Here is what you told us: Zip Code: 95115 Total household income: 536.180 Household members: 1 Age of Head of Household: 50 Years Needs Coverage? Household Includes: Pregnant Blind or Disabled Based on what you told us, here is what you may qualify for: You IlayQudllyior: Lower Premium It looks like you may qualify for a tax credit to lower your premium. More Information Preview Plans These results are only an estimate. You will need to complete an application. Back Appendix A - 8 of 11 cnivonuu Application Home FAQs leeChat 7 plans for 1 adult in ZIP code 95115. Coverage could start as early as Cal for help 1 -800-787-6921 premiums displayed have been reduced by your estimated tax Credit of $393.00 . Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used a Health Savings Account Metal Tier Platinum: hlghest premiums, lowest out of pocket costs Gold: hrgher premiums. lower outrofrpocket costs Silver: lower premiums, moderate outroflpocket (OSIS Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company Anthem Blue Cross so" By Premium (low to high) ADD TO CART it It HMO BRONZE Premium Primary Care VISits Drugs Yearty Deductic-le I-etal Expense Estrn? ate rty Rat ng COMPARE SI 00 a'tor $381.29 tax credit You pay $75 You pay 100? a $6300 5500 Ju'ay Apply: Lower I Ity Hatinq In ?ature VIEW DETAIL ADD TO CART Anthem hw- ll: 63 PO BRONZE 90 I?remlum Primary Care VISits Drugs Yearly Deductic-le I-etal Expense Estin? ate lty Rat ng COMPARE $70.36 a'tor $393.00 tax credit You pay $75 You pay 100? 3 $6300 9 $500 Applyi Lower I Ity Hatinq In ?ature VIEW DETAIL ADD TO CART Local Help ADD TO CART 2 Eh: EC H045 HMO BRONZE HSA HMO Premium Pr:mary Care Generic Drugs Yearly Deduct ble Iota Expense Estimate Ouallty Rating COMPARE $52 18 alter $393.001ax credit You pay 40: a You pay 40? a $4330 I?vldy No'. Aou?y) Lower Oual 1y Hating future VIEW DETAIL ADD TO CART 3 Anthem Blurfnm Bruno: v30 HD-IP EPO BRONZE Premium Pr:mary Care Generic Drugs Yearly Deduct ble Iota Expense Estimate Ouallty Rating COMPARE Appendix A - 9 of 11 HSA EPO $101.97 alter $393.001ax credit You pay 40? a You pay 40? S4acc I?i?ldv .3?;ny Lower Oual 1y Hating future VIEW DETAIL Logln Espa?olv ADD TO CART . i PSRMANENTF 'c Me '3 It BRONZE HMO Moothly Premium 853,33 a?ter $393.00 tax credlt P'i'nary Care You pay $75 Genenc Drugs You pay 100C 3 ., - $6300 5500 Year Juli?. Apply?l lotal Expense ate Lower - Ity Rating In rty Ratng ture COMPARE VIEW DETAIL ADD TO CART blue :?nrget?iIJIE-?E?l 5'50 BRONZE PSA Premium 8260 92 a?tor $393.00 tax credlt Primary Care You pay 40": Cohen: Drugs You pay 40?: ., 34800 Year Dedu-.ti..-le My lotal Expense Average Ity Rating In rty Ratng ture .J COMPARE VIEW DETAIL curvature Application Home FAQs leeChat 5 plans for 1 adult in ZIP code 95115. Coverage c0u d start as early as Cal for help 1 400-787-6921 premiums displayed have been reduced by your estimated tax credit ol $393.00 . Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used with a Health Savings Account Metal Tier Platinum: highest premiums. lowest out of pocket costs Gold: higher premiums, lower out of pocket costs Silver: lower premiums, moderate out of pocket COSTS Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company Anthem Blue Cross so" By Premium {low to high) ADD TO CART Silver SILVER Premium Primary Care Gene'rc D'ugs Yearly letal Expense Estrn?ate rty Rat ng COMPARE r-i ll MC HVO $182 32 a?ter $393.00 tax credit You pay $35 You pay 515 $2500 $130 kc! Apply: Lower - Ity Hatrnq in ?uture VIEW DETAIL ADD TO CART Anthem BIUH hm SILVER Premium Care Gene'rc Drugs Yearly letal Expense Qua rty Rat ng COMPARE Benefits Surr?mary sLla ii, . ,il :0 EP0 $353 94 a?ter $393.00 tax credit You pay $35 You pay $1 5 $2500 $130 Jy'uy Apply: Average Ity Ratrnq in ?uture VIEW DETAIL met I. Local Help ADD TO CART 2 1 im SILVER Premium Pr mary Care Ge"errc Drugs Yearly Deduct ble Iota Expense Estimate Oual ty Hating COMPARE MO 5292,85 alter $393.00 tax credit You pay $35 You pay 515 $2533 $133 I?i'Idv No: As: y: Averaqe Oual 1y Hating future VIEW DETAIL ADD TO CART blue SILVER Premium Pr mary Care Generic Drugs Yearly Deduct ble Iota Expense Estimate Oual ty Hating COMPARE Appendix A - 10 of 11 :1 P00 $516.74 alter $393 00 tax credit You pay $35 You pay 515 52533. $1.13" m?l Iy Au: Higher - Oual 1y Hating Iuture VIEW DETAIL Logln Espa?olv ADD TO CART blue er C-IHMO SILVER Premium Primary Care Visrts Generic Drugs Year letal Expense Estirr ate rty Rat ng COMPARE $331 27 a'ter $393.00 tax credit You pay $35 You pay 515 $2500 4? $130 I\t;l Average Qua Ity Rating in ?uture VIEW DETAIL cnivonuu Application Home FAQs leeChat 6 plans for 1 adult in ZIP code 95115. Coverage could start as early as Cal for help 1 -800-787-6921 premiums displayed have been reduced by your estimated tax Credit ol $393.00 9 Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used With a Health Sayings Account Metal Tier Platinum: highCSI premiums. lowest out of pocket costs Gold: hrgher premiums, lower out of pocket costs Silver: lower premiums, moderate out of pocket COSTS Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company Anthem Blue Cross so" By Premium (low to high) ADD TO CART r-r II GO-D HMO Premium l?rimary Care VISits Gene'ic Drugs Yearly letal Expense Estirr ate tty Rat ng COMPARE $250 48 a'tor $393.Apply: Lower I Ity Hatinq In ?ature VIEW DETAIL ADD TO CART blue Geld HMO T'u HMO Premium Primary Care VISits Gene'Ic Drugs Yearly letal Expense Eslirr ate rty Rat ng COMPARE $463 04 a?tcr $39300 tax credit You pay $he! Apply: Average Ity Ratinq In ?ulUlC VIEW DETAIL Benefits Sun?mary L) sLIa met I. . ,rr lF Local Help ADD TO CART . i G-slc 231'; HMO Cr; nau'u" 9e GOLD Premium Prmary Care Generic Drugs Yearly Deduct ble Iota Expense Estrmate Oualty Rating COMPARE NO 526703 alter $393V001ax creart You pay $N-TJ ?v Lower Oual Hating future VIEW DETAIL ADD TO CART 3 "323.12 all: GOLD Premium Prmary Care Generic Drugs Yearly Deduct ble Iota Expense Estimate Oualty Hating COMPARE Appendix A - 11 of 11 EPO EPO $508.36 alter $393 00 tax small You pay $25 You pay $15 SII Sn l?t?l. Iy Ali's.) 'p'l nghe' Oual Hating future VIEW DETAIL Logln Eepaholv ADD TO CART . i Gr; '1 Bl} Premium Primary Care Genenc Drugs Year, .. DeduetIC-le lelal Expense Ity Ratng COMPARE HMO $301 67 a?ter 5393.gI-i?uy he! Average Ily Rating In ?uture VIEW DETAIL ADD TO CART blue Qt? Gt. :1 82' P90 GOLD Premium Primary Care VISITS Oenenc Drugs Year Deductic-le letal Expen tty Rat no COMPARE PPO $651 65 a?tor 5393.00 tax ClOdll You pay $25 You pay $15 $0 30 allay Apply! Higher I- Ity Ratlnq In ?..ture VIEW DETAIL Case 3:17-cv-05895-VC Document 76-2 Filed 10/25/17 Page 1 of 11 State Regulators Have Improved Health Care Options for Lower-Income Consumers For a 60 year old living in San Francisco who earns 375% of the federal poverty level: Out-of-Pocket Monthly Premiums in 2017 Out-of-Pocket Monthly Premiums in 2018 Consumer Savings Per Month Bronze: $104 $1 Consumer Saves $103 Silver: $363 $366 Consumer Pays $3 More Consumer Switches to Gold and Saves $39 Gold: $464 $324 Consumer Saves $140 Monthly Tax Credit in 2017 Monthly Tax Credit in 2018 $580 $756 Appendix B - 1 of 11 Case 3:17-cv-05895-VC Document 76-2 Filed 10/25/17 Page 2 of 11 CHI for h? Find covulo Qumran?; Home FAQS Chat 1-800-787-6921 Local Help Log In I Espa?ol PREVIEW PLANS TELL US A LITTLE BIT ABOUT YOURSELF. Your information will help us ?nd out ifyou qualify for help paying for health coverage. Coverage Year: 20" 7 What is your Zip Code? 94108 What is your total income per year? $44,550 1) How many people are in your household? 1 Enter the age of each person in your household, and tell us if they need coverage. Age of Head of Household 60 4 Needs Coverage? Is anyone in your household pregnant? Yes Is anyone in your household blind or disabled? Yes Back 300 My Results Appendix - 2 of 11 Case 3:17-cv-05895-VC Document 76-2 Filed 10/25/17 Page 3 of 11 1-800-787-6921 Local Help I Find itli $33352 Application Home FAQs leeChat Ca Logln Espanolv 0 MY OPTIONS Here is what you told us: Zip Code: 94108 Total household income: 544.550 Household members: 1 Age of Head of Household: 60 Years Needs Coverage? Household Includes: Pregnant Blind or Disabled Based on what you told us, here is what you may qualify for: You IlayQudllyior: Lower Premium It looks like you may qualify for a tax credit to lower your premium. More Information Preview Plans These results are only an estimate. You will need to complete an application. Back Appendix - 3 of 11 Find Local Help cnivonuu 1 787 1 Log In Espa?ol Application Home FAQs leeChat Back to prele'enees ?mm PLANS DENTAL PLANS CART 0 9 plans for 1 adult in ZIP code 94108. Coverage could start as early as premiums displayed have been reduced by your estimated tax credit 01 $580.00 I Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used a Health Savings Account Metal Tier Platinum: hlghest premiums. lowest out of pocket costs Gold: hrgher premiums. lower out of pocket costs Silver: lower premiums, moderate out of pocket COSTS Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to 5999 $1000 to 52499 52500110 54999 so" By Premium (low to high) ADD TO CART 4? A l" Barge BRONZE Premium l?ri'nary Care ViSits Drugs Yearly Deducticle l-otal Expense Estin?ate ity Rat ng COMPARE $86106 a'ter $580.00 tax credit You pay $75 You pay 100? 3 36300 $500 Apply: Lower I VIEW DETAIL ADD TO CART E'ru'ue {=13 EPO BRONZE Premium Primary Care ViSits Gene'Ic Drugs Yearly Deductiole lotal Expense Estrn? ate rty Rat ng COMPARE $209 13 a?ter $58000 tax credit You pay $75 You pay 100: 3 $6300 3500 he! Apply: Lower II Ity Ratinq in ?uture VIEW DETAIL ADD TO CART . i -l HMO Premium Prmary Care Visns Generlc Drugs Yearly Deduct ble lota Expense Estimate Oualty Rating COMPARE $103.61 alter $580 00 tax mean You pay $75 You pay 100": 5633-3 l?vluv A: Lower VIEW DETAIL ADD TO CART A tthe I nluKim v31} EPO BRONZE Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Tota Expense Estlmate Oualrty Hating COMPARE Appendix - 4 of 11 HSA E90 $215.39 alter $580 00 tax :rezlrt You pay 40? a You pay 40? 3 l?i?lzly AUUIV: Lower i IT: 132?: VIEW DETAIL ADD TO CART . a {in BRONZE Moothly l?remlum Primary Care VISits Genenc Drugs Year Deductic-le lotal Expense ate rty Ratrng COMPARE 8109 24 a?ter tax CICdll You pay 40": You pay 40": $4800 he! Lower II itiit VIEW DETAIL ADD TO CART Anthem ?Ill-4 Drum Err: no: '31} EPO BRONZE E90 Moothly l?remlum Primary Care VlSits Oenenc Drugs Year Deductiole lotal Expense ate OUJIXV Ratrng COMPARE 8232 O3 a?ter 558C200 tax CIOdll You pay $75 You pay 100c 2 $6300 1? $500 allay l\L?t Apply-1 Lower I- if: VIEW DETAIL Find Local Help cnivonuu 1 787 1 Log In Espa?ol Application Home FAQs leeChat Back to prele'enees DENTAL PLANS CART 0 HEALTH PLANS 7 plans for 1 adult in ZIP code 94108. Coverage could start as early as premiums displayed have been reduced by your estimated tax credit 01 $580.00 a Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used a Health Savings Account Metal Tier Platinum: hlghest premiums. lowest out of pocket costs Gold: hrgher premiums. lower out of pocket costs Silver: lower premiums, moderate out of pocket COSTS Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to 5999 $1000 to 52499 52500110 54999 so" By Premium (low to high) ADD TO CART 4? A l" 7'3 SILVER Premium l?ri'nary Care ViSits Drugs Yearly Deducticle lotal Expense Estin?ate ity Rat ng COMPARE $283 99 a'ter $580.00 tax credit You pay $35 You pay 815 $2500 $250 Apply: Lower I VIEW DETAIL ADD TO CART blue SIT-.71 P50 SILVER Premium Primary Care ViSits Gene'Ic Drugs Yearly Deductiole lotal Expense Estrn? ate Qua rty Rat ng COMPARE 9P0 $447 27 a?ter $58000 tax credit You pay $35 You pay 515 $2500 1' $250 he! Apply: Average if? 1: 71? VIEW DETAIL .1, SILVER Premium Prmary Care Visns Generlc Drugs Yearly Deduct ble lota Expense Estimate Oualty Rating COMPARE ADD TO CART . i ?a ?3 MO 5362,63 alter $580 00 tax mean You pay $35 You pay 515 $2503 $258 l?vluv .Auu?jvf Averaqe VIEW DETAIL ADD TO CART blue Ct? 13 SILVER Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Tota Expense Estlmate Oualty Hating COMPARE Appendix - 5 of 11 ?13 141le $474.78 alter $580 00 tax :rezlrt You pay $35 You pay $15 5259?.) $253 I?i'Izly AUUIVI Averaqe Oual 1y Hating future VIEW DETAIL ADD TO CART Si v-jl E30 Moothly l?remlum Primary Care VISits Genenc Drugs Year Deductic-le lotal Expense ate rty Ratrng COMPARE EPO 8445 67 a?ter $580.00 tax You pay $35 You pay 515 $2500 2 $250 he! Average Ily Ratlnq in ?uture VIEW DETAIL ADD TO CART Anthem ?Ill-4 Drum Eil'nj' EP0 (In US: SLVER Moothly l?remlum Primary Care VlSits Oenenc Drugs Year Deductiole lotal Expense ate OUJIXV Ratrng COMPARE EPO $573 15 a?tor 558C200 tax ClOdlI You pay $35 You pay 515 $2500 1? $250 allay l\L?t Apply-1 Average if: VIEW DETAIL Find Local Help cnivonuu 1 787 1 Log In Espa?ol Application Home FAQs leeChat Back to prele'enees ?mm PLANS DENTAL PLANS CART 0 8 plans for 1 adult in ZIP code 94108. Coverage could start as early as premiums displayed have been reduced by your estimated tax credit 01 $580.00 a Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used a Health Savings Account Metal Tier Platinum: hlghest premiums. lowest out of pocket costs Gold: hrgher premrums. lower out of pocket costs Silver: lower premiums, moderate out of pocket COSTS Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to 5999 $1000 to 52499 52500110 54999 so" By Premium (low to high) ADD TO CART . i 3 PFRMANENTF (3.: 1 8C- HMO Premium l?ri'nary Care ViSits Drugs Yearly Deducticle letal Expense Estin?ate ity Rat ng COMPARE $463 92 a'ter $580.00 tax credit You pay $Apply: Average VIEW DETAIL ADD TO CART Gr; 83 E50 GOLD Premium Primary Care ViSits Gene'Ic Drugs Yearly Deductiole lotal Expense Estrn? ate rty Rat ng COMPARE EPO $608 21 a?ter $58000 tax credit You pay $he! Apply: Average Ity Ratinq in ?uture VIEW DETAIL ADD TO CART It (331C :33 GOLD Premium Prmary Care Visns Generlc Drugs Yearly Deduct ble lota Expense Estimate Oualty Rating COMPARE 4130 548518 alter $580 00 tax mean You pay $l?vluv Asa?) Averaqe titt? VIEW DETAIL ADD TO CART blue Qt? Gall: GOLD PPO Premium $695.31 alter $580 001ax :rezlrt Prmary Care You pay $30 Generic Drugs You pay 5155 Yearly Deduct ble Aw.? Tota Expense Estlmate Averaqe Oualrty Hating i If: "it If? COMPARE VIEW DETAIL Appendix - 6 of 11 ADD TO CART . a Gr; '1 Bl} I'lle HMO Moothly l?remlum Primary Care VISits Genenc Drugs Year Deductic-le lotal Expense ate rty Ratrng COMPARE $512 52 a?ter $580.he! Average itiit VIEW DETAIL ADD TO CART blue l?lle HMO Moothly l?remlum Primary Care VlSits Oenenc Drugs Year Deductiole lotal Expense ate Ity Rat no COMPARE $699 31 a?tor 558C200 tax ClOdll You pay $30 You pay $15 $0 $0 allay l\L?t Apply-1 Higher Qua Ity llatlnq in ?uture VIEW DETAIL Case 3:17-cv-05895-VC Document 76-2 Filed 10/25/17 Page 7 of 11 CHI for h? Find covulo Qumran?; Home FAQS Chat 1-800-787-6921 Local Help Log In I Espa?ol PREVIEW PLANS TELL US A LITTLE BIT ABOUT YOURSELF. Your information will help us ?nd out ifyou qualify for help paying for health coverage. Coverage Year: 20" 8 What is your Zip Code? 94108 What is your total income per year? $45225 1) How many people are in your household? 1 Enter the age of each person in your household, and tell us if they need coverage. Age of Head of Household 60 4 Needs Coverage? Is anyone in your household pregnant? Yes Is anyone in your household blind or disabled? Yes Back 300 My Results Appendix - 7 of 11 Case 3:17-cv-05895-VC Document 76-2 Filed 10/25/17 Page 8 of 11 1-800-787-6921 Local Help I Find itli $33352 Application Home FAQs leeChat Ca Logln Espanolv 0 MY OPTIONS Here is what you told us: Zip Code: 94108 Total household income: 545.225 Household members: 1 Age of Head of Household: 60 Years Needs Coverage? Household Includes: Pregnant Blind or Disabled Based on what you told us, here is what you may qualify for: You IlayQudllyior: Lower Premium It looks like you may qualify for a tax credit to lower your premium. More Information Preview Plans These results are only an estimate. You will need to complete an application. Back Appendix - 8 of 11 Find Local Help cnivonuu 1 787 1 Log In Espa?ol Application Home FAQs leeChat Back to prele'enees ?mm PLANS DENTAL PLANS CART 0 9 plans for 1 adult in ZIP code 94108. Coverage could start as early as premiums displayed have been reduced by your estimated tax credit ol $756.00 a Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used With a Health Savings Account Metal Tier Platinum: hrghest premiums. lowest out of pocket costs Gold: hrgher premiums. lower out of pocket costs Silver: lower premiums, moderate out of pocket COSTS Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to 5999 $1000 to 52499 52500110 54999 so" By Premium (low to high) ADD TO CART 4? A l" Barge HMO BRONZE I430 Premium l?ri'nary Care ViSits Drugs Yearly Deducticle l-otal Expense Estin?ate ity Rat ng COMPARE I. $1 00 a'ter $124.94 tax credit You pay $75 You pay 100? 3 30300 $500 Apply: Lower I VIEW DETAIL ADD TO CART Burs-3 l?El?P BRONZE Premium Primary Care Vi5its Gene'Ic Drugs Yearly Deductiole lotal Expense Estrn? ate Qua rty Rat ng COMPARE 45A $1 51 a?ter Sit 1' tax credit You pay 40% You pay $4800 he! Apply: Lower II VIEW DETAIL ADD TO CART . i Eh; EC BRONZE Premium Prmary Care Visns Generic Drugs Yearly Deduct ble lota Expense Estimate Oualty Rating COMPARE HSA HMO $1.02 alter 51 tax mean You pay 40? a You pay 40? 3 S4BCC l?vluv Acu?yf Lower tittifr VIEW DETAIL ADD TO CART 050le Bronze '31} EPO BRONZE Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Tota Expense Esttmate Oualty Hating COMPARE Appendix - alter $556 00 tax credit You pay 40? a You pay 40? 3 $4892 I?i?lzly AUUIV: Lower Oual 1y Hating future VIEW DETAIL ADD TO CART . a E'n; Me BRONZE HMO Moothly Premium Primary Care VISits Genenc Drugs Year Deductic-le lotal Expense ate rty Rating COMPARE 81 O2 a?ter $129.40 tax You pay $75 You pay 100C 3 $5300 2 $500 he! Applyi Lower II ittitir VIEW DETAIL ADD TO CART Err: no: '31} EPO BRONZE E90 Moothly Premium Primary Care VISits Oenenc Drugs Year Deductiole lotal Expense ate Ity Rat no COMPARE $58.06 a?ter 5/5600 tax credit You pay $75 You pay 100c 2 $6300 $500 l\L?t Apply-i Lower I- Ity Ratlnq in ?uture VIEW DETAIL cnivonuu Back to prele'ences Application Home FAQs leeChat 6 plans for 1 adult in ZIP code 94108. Coverage could start as early as 1-800-787-6921 premiums displayed have been reduced by your estimated tax credit ol $756.00 i Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used With a Health Savings Account Metal Tier Platinum: highest premiums. lowest out of pocket costs Gold: higher premiums. lower out of pocket costs Silver: lower premiums, moderate out of pocket COSTS Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to 5999 $1000 to 52499 52500110 54999 so" By Premium (low to high) ADD TO CART 4? A l" 7'3 SILVER Premium l?rimary Care ViSits Drugs Yearly Deducticle letal Expense Estin?ate ity Rat ng COMPARE $310 09 a'ter $156.00 tax credit You pay $35 You pay $1 5 $2500 $130 Ju?ay Applyi Average VIEW DETAIL ADD TO CART blue St P50 SILVER Premium Primary Care Vi5its Gene'ic Drugs Yearly Deductiole letal Expense Estirr ate Qua ity Rat ng COMPARE PPO $523 99 a?ter tax credit You pay $35 You pay $1 5 $2500 1' $130 he! Applyi Average if? 1: 71? VIEW DETAIL .1, SILVER Premium Prmary Care Visns Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE Local Help HEALTH PLANS ADD TO CART . i ?3 5366,39 alter $.56 00 tax credit You pay $35 You pay 515 52513-35138 l?vluv Acu?yf Averaqe it VIEW DETAIL ADD TO CART 050le 3 lue' SILVER Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Tota Expense Estimate Quality Rating COMPARE Appendix - 10 of 11 ?3 EP0 EDO $530.85 alter $556 00 tax credit You pay $35 You pay 515 5256-3 $133 l?t'Lly AUUIV: Averaqe Oual 1y Hating future VIEW DETAIL Logln Espa?olv DENTAL PLANS CART 0 ADD TO CART blue vi?l Til HMO .: SILVER Premium Primary Care ViSits Generic Drugs Year Deductic-le l-olal Expense Estirr ate ity Rating COMPARE 8471 44 a?ter $156.00 tax credit You pay $35 You pay 515 $2500 2 $130 away he! Applyi Average ily Rating in ?uture VIEW DETAIL ADD TO CART (9 Health Net? 7'2 SLVER Moothly Premium Primary Care ViSits Oenenc Drugs Year Deductiole letal Expense Eslirr ate Ouaity Rating COMPARE EPO $734 70 a?ter 5/5600 tax credit You pay $35 You pay 515 $2500 $130 hut Apply-i Higher if: VIEW DETAIL cnivonuu Back to prele'ences Application Home FAQs leeChat 7 plans for 1 adult in ZIP code 94108. Coverage could start as early as 1-800-787-6921 premiums displayed have been reduced by your estimated tax credit ol $756.00 i Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used With a Health Savings Account Metal Tier Platinum: highest premiums. lowest out of pocket costs Gold: higher premiums. lower out of pocket costs Silver: lower premiums, moderate out of pocket COSTS Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to 5999 $1000 to 52499 52500110 54999 so" By Premium (low to high) ADD TO CART . i 3 PFRMANENTF (3.: 1 8C- HMO Premium l?rimary Care ViSits Drugs Yearly Deducticle letal Expense Estin?ate ity Rat ng COMPARE $324 13 a'ter $156.00 tax credit You pay $Ju?ay Applyi Average VIEW DETAIL ADD TO CART Gr; :1 83 E50 GOLD Premium Primary Care Vi5its Gene'ic Drugs Yearly Deductiole letal Expense Estirr ate ity Rat rig COMPARE EPO $662 86 a?ter tax credit You pay $he! Applyi Average ity Ratinq in ?uture VIEW DETAIL Local Help HEALTH PLANS ADD TO CART It (331C :33 GOLD Premium Prmary Care Visns Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE >wo 5376,63 alter $.56 00 tax credit You pay $l?vluv Acu?yf Averaqe titt? VIEW DETAIL ADD TO CART blue Ct? 63 -: 3C GOLD Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Tota Expense Estimate Quality Rating COMPARE Appendix - 11 of 11 Tr-: >ll.?O $694.73 alter $556 00 tax credit You pay $25 You pay $15 Qn sn r?t'Lly K12): AUUIV: Averaqe Oual 1y Hating future VIEW DETAIL Logln Espa?olv DENTAL PLANS CART 0 ADD TO CART . a Gr; '1 Bl} HMO Premium Primary Care ViSits Generic Drugs Year Deductic-le l-olal Expense Estirr ate ity Rating COMPARE 8380 82 a?ter $156.00 tax credit You pay $25 You pay $15 $0 $0 away he! Applyi Average ittitir VIEW DETAIL ADD TO CART blue Gr: :l 82' GOLD Moothly Premium Primary Care ViSits Oenenc Drugs Year Deductiole letal Expense Eslirr ate Ouaity Rating COMPARE PPO $713 80 a?ter 5/5600 tax credit You pay $25 You pay $15 $0 $0 hut Apply-i Higher if: VIEW DETAIL Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 1 of 17 State Regulators Have Improved Health Care Options for Lower-Income Consumers For a 30 year old living in El Monte who earns 225% of the federal poverty level: Out-of-Pocket Monthly Premiums in 2017 Out-of-Pocket Monthly Premiums in 2018 Consumer Savings Per Month Bronze: $108 $121 Consumer Pays $13 More‡ Silver: $198 $204 Consumer Pays $6 More Consumer Switches to Gold, Pays $15 More Gold: $261 $219 Consumer Saves $42 Monthly Tax Credit in 2017 Monthly Tax Credit in 2018 $66 $123 ‡ Even though this is an increase, remember that the pre-tax credit price for most plans in California went up between 2017 and 2018. Absent the increased tax credit generated by the regulators’ response to the Administration’s decision to stop CSR payments, the consumer would have paid even more in 2018 for the bronze plan. Appendix C - 1 of 17 Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 2 of 17 . Calforhelp Find 5333?}: Application Home FAQs UveChat moo-73743921 I Local Help Log In Bpanolv 0 PREVIEW PLANS TELL US A LITTLE BIT ABOUT YOURSELF. Your ir?ormation II help us out you qualify for help pay ng for health coverage. Coverage Vear: 2017 What is your Zip Code? 91735 What is your total income per year? 526730 How many people are in your household? 1 Enter the age of each person in your household. and tell us if they need coverage. Age of Head of Household 30 Needs Coverage? Is anyone in your household pregnant? Yes Is anyone in your household blind or disabled? Yes Back soouymu Appendix - 2 of 17 Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 3 of 17 Cdlforhob Hm! I I I IHolp LognlEspa?oV 0 @5333}: Application Home I FAQs LiveChat 1-eoo7a7 m1 MY OPTIONS Here is what you told us: Zlo Code. 91735 Total nausorod noo'nc, 526.730 Heuscrold members. 1 Age 0? Head of Household 30 Years Nocds Covc'agc? Household Includes Pregnant or Disabled Based on what you told us, here is what you may qualify for: Lower Premium It loollJC HVO 5? 73.04 alte' 556 CC tax yeaApply. Lowu? - VIEW DETAIL ADD TO CART SHEER PPO Prom arr? Ca'u a I: Ge'mnu Dug-J Yoa' EumeIL-Ip laia Lap-cast On Rall'rg COMPARE $97.79 b' tax recLIU 52?.le Agplw Average VIEW DETAIL Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 7 of 17 Find Local Help Cdlforhob rectum-em I culvouu Application Home LIvoChat Metal Platinum: hrghes: orem u~s, lowest cut-o?- oocket (0515 Gold: higher ower OJt-ol-pouet costs Silver: lower prmlumS, "'ocerale out-oI-pcckel (0515 Bronze: lowest orem u~s, highest out-ol- Docket costs Yearly $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company Anthem Blue Cross Blue Shield Health Net Kaiser LA Care Molina Health Care Quallty Rating i COMPARE VIEW DETAIL ADD TO CART blue 3 ga" 3 PHIO P'err' P'Ill'dl?y Carr: (jar-nu. [3'ng DQLILLI cl?: lu-lul Lxuc'lw: 'rml?: ly Hal 'Ig COMPARE $186 23 aft-2r 56": 0'3 tax crecrl Yca pay $30 Yua pay 5 SLIUU L. .. L'ch' - l?l VIEW DETAIL ADD TO CART mus 3 3.. 4 3 P'urr' Carr: Vl'a'lIb Ger-3h; [3'ng DQLILLI uh: Lxuvrw: le 'rml?: I'y Hal 'Ig COMPARE after 3.06; tax crecrl Yuu pay $30 Ycu pay 515 UL: km. Av?e'ugc VIEW DETAIL Uriel I) ulum [Jun "Hal 15 31-; dl?llL? COMPARE VIEW DETAIL ADD TO CART F. SILVER p, ~va Cur?: :13 1; Drugs L?eum?lt lulu pr?n?w Hullr'g COMPARE ?3 $188 ~19 a?ter Stew Lax radii Vc-u awNci Lcwer - C19 R11 Fun! .Il? VIEW DETAIL ADD TO CART F. Pr "ld'y? Cur-'3 :15 Drugs :rr ?v I: lulu Lu; Hullr?g COMPARE Appendix - 7 of 17 525?:- 87 a?ter St. 30131 :redlt Vou ua'y 33C Vc-u way 51 5 .21 'w Nc?. ll g'w' - i VIEW DETAIL COMPARE VIEW DETAIL ADD TO CART PPO Prern P'mdry Cd'c V: I: Dug: Y-ru' 3' I. L?meIL-lc luid Ou COMPARE alte' ?bb.1. ?-l-rl Ampl'u Average VIEW DETAIL Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 8 of 17 Find Local Help Cdlforhob rectum-em I culvouu Application Home I FAQs UvoChat 9 plans for 1 adult in ZIP code 91735. Caverage cou start as ca'ly as 0150152017. lu'oml?ly prom ums splavcd have bccr? reduced by your 051 mated 3? tax :redt 01566 CC- By Plan Type HMO PPO EPO Plan Features CSR Eligible udes (051 Shaun); (owe' out-ol-potket costs! HSA Compatible Ca". 38 usec With a Healm Savings Atccuri Metal Tucr Platinum: highest Diem u~s, lowest cut-o?? oocket costs Gold: higher p'ewiums. o'her out-oI-pouet tests Silver: lower premiums, ?oderaie out-oI-pc:kel (0515 Bronze: lowest arem u~s, l?lgl?ESK Out-ol- socket (0515 Yearly $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 Sort By Toia Experse Estimaie ADD TO CART 0 M89335. Gull} GOLD P'un? Lin] P'Ill?dl'y Curr: Goren. 0?]ng You'll [3":qu 1.1 onmw.? 'nuln: {Jud Iy Hal 'ig COMPARE blu HAO $183.64 all-2r 5.6503 tax crecn Ycu pay $VIEW DETAIL ADD TO CART 9@ GM GOLD FWD P'un? Lin] 5239.88 P'Ill'dl?y Curr: \ll'a'll'a Govern D?ng You?l'y Dodo-.1 Cl?: onv: 'nulv: Odd Iy Hal 'Ig COMPARE aft-2r 5.65:0? tax tie-f-"J All; Av?e'ugu Om Hating luturL? VIEW DETAIL ADD TO CART ADD TO CART F. mam. 3' HIJ ?Au'il'll?y l-?r "ld'y? Cur?: :15 5 Drugs "11? ?v Douuctlt I: lulu proi?w Lzatimzill: Uudlily Hulii'g COMPARE .~\nlht $234 1.1 a?ter Stew lax :rediNat Au'eiugi: 2-1' VIEW DETAIL ADD TO CART F. ?11) 3 HIJ hrs-1 l-?r "id'y' Cur?: a ?35 Drugs "12? 'v Dos I: lutu proi? Hulii'g COMPARE Appendix - 8 of 17 $245 ~12 a?ter Stew [5.x radii Vc-u SEC You may 515 .81? Nu" Au'ciugi: Cm? Ohm"; :11! Anni 9 VIEW DETAIL ADD TO CART F. (9 Health Net? I COLD lulur'ili?y Prom urr? Cd'l.? V: I: Go'imu; Dng?: You' 3' lutu Qualify Ruling COMPARE 3 .1 ch: ADD TO CART .2, C- $235.22 alte' 556 CC tax yeaELI szpl'u Average VIEW DETAIL ADD TO CART M301 maummr 13.! a: COLD Prom urr? P'I'Ildl',? Cd'u a I: Generic Drug-J You' 3' EumeIL-lu laid Ou ulit'; Ruling COMPARE $249.33 alte' 556 CC tax recAgplw Average VIEW DETAIL ADD TO CART I Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 9 of 17 IIA Application Home Metal Platinum: hlghes?. stem u~s, lowest cut-o?- oocket costs Gold: higher p'e'?ums. uwer Oat-oI-pouet costs Silver: lower premiums, ?ocerate out-ol-pccket (0515 Bronze: lcwest stem uws, t?lgl?est cal-cl? Docket costs Yearly $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company Anthem Blue Cross Blue Shield Health Net Kaiser LA Care Molina Health Care Quallty Rating i iti?f Uvo Chat for hob 1 -800-787-6921 Qaa I?y Hal 'Ig 1 I 1: COMPARE VIEW DETAIL ADD TO CART blue C. 'll'i 5" COLD I?lorl'lly P'err? u"1 P'Irr'ary Can: Vlb'llb Goren. U'agu Yua'l',? uln: Lxums?: Lal 'nalu: Qaa I?y Hal 'Ig COMPARE blu l? $239.88 after 56"; 03 tax ctecn Yua pay 530 Yca pay 51 5 SL1 Ix?l Paul. Av?u'agu Qua laiaru VIEW DETAIL ADD TO CART 'xld 5. COLD Norl'lly P'en? u?w P'Irr'ary Can: Goren. U'ng Yca'l',? all: L::l 'naln: Qaa I?y Hal 'Ig COMPARE PPO $261.43 after $65.03 tax creCIl Yua pay $30 Yca pay 515 SL: IlJa'; l-mt Apt. 9?12! 3' VIEW DETAIL Esau-l an L) alum Qua :2 L) dl'llL" - l-?r "ld?y? Caro 2 .3 Find Local Help Haln'g i i ?t I 1; COMPARE VIEW DETAIL ADD TO CART F. Anthem ?In?ow-u 3' V: -ll.'C 33-3 >ll.?C ?Ac'll'll?y P'c'mun $243 ~12 a?tel SL1: JL, tax redl a; Clogs ar 'v ac?JL? I: lula Lullmalu Hatu'g COMPARE You 315 5L: WIM- Nc?. Ale-yv Avmagu Cw A a ~24 VIEW DETAIL ADD TO CART F. .msuz P1 3' all": 33-3 ?Ac'll'll?y P'c'muu Caro 5 f5 Gu?m' Ullng' ?v?car 'v Deuacilt; I: l'J'a pr-?grau Lutunalu Halu?g COMPARE Appendix - 9 of 17 >llt? 3 $263 69 a?tet St): ?30 tax radii You ua'y 53C You 515 Nc?. Ale-yv ll - VIEW DETAIL Logln Espal'lolv Quality Halng 1 I i COMPARE VIEW DETAIL ADD TO CART Mam "nu/mom Gr -: :Zv COLD HVO lylut'ili'y Prom arr P'vnat'; Can; I: Go'wna.? Dug: Yo'Ja' 1 luta Lapcwz?c at?: Quality Halmg COMPARE 5240.03 alteELI Average VIEW DETAIL ADD TO CART ?Hm F, It; 37? COLD EPO lt?lut'ili?y Prom arr P'maly Can: V: I5 Ge'lenu Dug: Yo'Ja' luta Qualify Hdll'lg COMPARE 53-1083 alte' 556 CC tax :'eot You pay $VIEW DETAIL Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 10 of 17 carom? I Local Help I 39350" 0 53:25:52 Application Home FAQs Live Chat 1-800-787-6921 PREVIEW PLANS TELL US A LITTLE BIT ABOUT YOURSELF. Your ir?ormation II help us out you qualify for help pay ng for health coverage. Coverage Vear: 2013 9 What is your Zip Code? 91735 What is your total income per year? $27135 How many people are in your household? 1 Enter the age of each person in your household. and tell us if they need coverage. Age of Head of Household 30 Needs Coverage? Is anyone in your household pregnant? Yes Is anyone in your household blind or disabled? Yes 33?? 300 My mt: Appendix - 10 of 17 Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 11 of 17 Cdlforhob Hm! I I I IHolp LognlEopa?oV 0 @5333}: Application Home I FAQs LivoChat 14,0078? m1 MY OPTIONS Here is what you told us: Zlo Code. 91735 Total nausorod noo'nc, 527.135 Heuscrold members. 1 Age 0? Head of Household 30 Years Nocds Covc'agc? Household Includes Program Blind or Disabled Based on what you told us, here is what you may qualify for: Lower Premium It looil.?C ERORZE HVO P'mat'; Ca'u V: I: Ge'lenu Dug: Yoa' Bede-31bit: luta prc?m.? Hdll'ig COMPARE You pay 575 You pay 100": "Jay Lowe." - VIEW DETAIL ADD TO CART Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page culvonuu $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company Blue Shield Health Net Health Net Kaiser LA Care Molina Health Care Oscar Health Plan Quality Rating i Application Home I FAQs UvoChat Qua I?y Hal 'Ig COMPARE 69 Health Net' Eu '11::4 hl_ BRONZE um P'lrl?dl?y Can: Vlb'llb Ger-3h. Dug-J lug-LII Lxums?: Qua I?y Hal 'Ig COMPARE LJJIL - Qua IJ Find Cdlforhob 1 -800-787-6921 Lutlmalu Gaaltly Hullt?g {Jr-3 VIEW DETAIL COMPARE ADD TO CART Ev $134.57 aft-2r DU lax ?ch'il'll?y Yua pay 575 Pt "ld?y? Cari: is pay 130?, t; [5,5723% 4.11:1, V: "?L?ar 'v BatmanLainnalc Qaaltly' Halit'g VIEW DETAIL COMPARE ADD TO CART r. blue ~93 m: rr'c- BROINZE U"l P'Irl?dl?y Catt: Vl'illb U'agb Lil?: Lxuc'lzin: Lal 'nalc Qaa I?y Hal 'Ig COMPARE 45A FPS 5112 19 aft-2r 51:: 3U [51 C'eon Yua pay 43". Yua pay away to: Am. Luv-1" - VIEW DETAIL Uriel l3 avelam Appendix - 13 of 17 Local Help -- i VIEW DETAIL ADD TO CART F. 5-1-3 EPO 813? 103 a?tet 312;! CC tax crecn Vc-u pay Vc-u way Why Nc?. Apply Luwm ()Lall'sv Hal 'l VIEW DETAIL Logln Espa?olv Qualify Hali')g COMPARE VIEW DETAIL ADD TO CART mam Eu m3: 4ft?: BRONZE lulux'ili?y I-?tetn arr Can: [5 Yea' E's-Jumble Izta prc?wc in" ail; Quality Hdll'lg COMPARE You pay pay L-?J?hu' - VIEW DETAIL Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 14 of 17 culvouu Application Home I FAQs UvoChat 8 plans for 1 adult in ZIP code 91735. cou start as early as Cdlforhob 1 -800-787-6921 Find Iv'omr?ly prom urns splaycd rat-c beer by you 051 mated marth tax cred! 0151237134:- Filler By Plan Type PPO HMO EPO Plan Features CSR Eligible Inc udes cost sharing 'e0ucuor?s Iowe' out-cl-pocket HSA Compatible Cr. 32 ?sec With .3 Healt". Savings Metal Tier Platinum: hlghes?. Drem uws, lowest Docket (0315 Gold: higher O'hef (051$ Silver: lower premlums, ?ocerale out-ol-pcckel (0515 Bronze: lowest orem I?Igl?est Oql-Ol- socket (0315 Yearly $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 and nupr Son By Toia Exoerse Estimate ADD TO CART 3 I?loi?l?Ily P'en' u"1 P'Ill'dl?y Cam Vlb?lIb Ger-3h. [3'ng cl?: lu-Inl Lxuv."lm: LEI 'nnl?: l'y Hal 'Ig COMPARE 1 $1 58114 after 312': LIL: tax :necm Yca pay $30 Yca pay 515 SLLULI 313?; :Ihx? Am. busy I VIEW DETAIL ADD TO CART (9 Health Net' 3 P'un' P'Ill?dl?y Can: Vlb?llb Ger-3h. Dug-J Cl?: 'nulv: Hal 'Ig COMPARE -. PPO $199.51 after 312': DC tax real: Yca pay $30 Yua pay $15 SLEUU il.?.w =7 Am. Av?e'dgu (Jun lJiJrL? VIEW DETAIL ADD TO CART Local Help ADD TO CART F. a? Health Net' - 3. P'c'nlun 516?: a?ter 3123 CC fax Pr "id?y Cur?: :15 51:1? 1 lulu pr-?si?w L-J'Jmulu Hullr?g COMPARE bl? 3. P'c'muu I-?r "my Car?: ":15 z; [31ng at? \v Lleumxlt lutu pr-?gr?ac Lzatunull: Hullr?g COMPARE Appendix - 14 of 17 mean Vc-u UdNc?. ApLIyr Average VIEW DETAIL ADD TO CART F. e@ 3.1.3 5234 2C a?ter 3123 CC ta): cvec? Vc-u 53C Vou yer,- $15 3 ELIE 51 . 'n Nc?, Au'eidgi: VIEW DETAIL ADD TO CART F. Logln Espal'lolv ADD TO CART blue Qt? -. 1 Ha": Tr . luIc-i'tlw' Pram urr' P'I'Ildl'f Cd'u Vs I: Dug-J Y-ru' luid Ou allt'; Ruling COMPARE a 3' 23 CO tax 2, :11Anal-u Average (.Lml ly Hair?; VIEW DETAIL ADD TO CART I mun maummt Ella-2' ?3 ELVER lt-Ic-i'tl'w' Pram urr' V: I: Ge'ienu Dug: lutd Ou Ruling COMPARE $224.3' a 12' 5' 2: CO tax :redlQ'su Average i VIEW DETAIL Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 15 of 17 Find Local Help (killorlu?p Login Espai'lolv ?we? rectum-em Application Home I Platinum: mghes: stem u~s, lowest cut-o?- oocket costs Gold: higher p'e'viums. o'her Out-ol-pouet tests Silver: lower premiums, ?ocerate out-ol-pccket (0515 Bronze: lowest stem u~s, highest socket costs Yearly $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company Blue Shleld Health Net Health Net Kaiser LA Care Molina Health Care Oscar Health Plan Quallty Rating COMPARE (9 H93 3 ?7 E'ha VIEW DETAIL ADD TO CART Net' .. PPO $199.51 after 51:: 30 tax :'eon Can: Vl'illb Get'erc D'ng Yearly Lal 'nulc 0.1a I?y Hal COMPARE P'utr u"1 Can: ?Jmlb Ger-3h; [3'ng ?rwI; 0thth cl?: Lxuvrlm: le 'nul?: l'y Hal 'Ig COMPARE aw, I) BLIJ 00 Ycu pd? S30 Yuu pay 515 tlt?xw Ix.? Ave'uge Ow VIEW DETAIL ADD TO CART Annual 1., it 5237.95 alter 512?: DC tax ream Yua pay $30 Ycu pay 515 52.00 Apt. Av?e'ugc VIEW DETAIL [Jun "Hal 15 31-; dl?llL" COMPARE VIEW DETAIL ADD TO CART F. Wet? 7173.?) ?Ac'tl'll?y P'c'mun P?l"1d?y? Cur-?1 15 Gum." t; Dug-s ?'L?dl \v Lia-mum; n: lulu Lalutmlt.? Huin'g COMPARE 3.1.3 3234 2C a?tet 512:5 CC tax Vuu $30 Vc-u My 515 5420?: SI .31 Ntr?. Average VIEW DETAIL ADD TO CART F. Sir-:22. 23-3 ?Ac?tl'lly P?tc'nlun Pr "id'y? Cur-'3 :15 t; Duly-j at ?v I: lulu Lu; Lalutmlu Hullt'g COMPARE Appendix - 15 of 17 $239 62 a?ter 3123 CC tax crecll Vou my $30 Vc-u Si 5 3420; SI Nc?. ll g'w' - Hui ?l VIEW DETAIL COMPARE VIEW DETAIL ADD TO CART Mam nnummr Tl -llt'C lvlut'ili'y Pram 'th? P'nndt',? Cd'l.? I: Go'lcnc Dug: Yo'm' laid Lapel?: Lu. "1m: Ouull'sy Rdll?ig COMPARE 5'31; .1, "of! Average VIEW DETAIL Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 16 of 17 [Jam in Application Home I FAQs UvoChat 9 plans ior1 adult in ZIP code 91735. Cavcrage cou start as ca'ly as (ll/0112018. for hob 1 -800-787-6921 Find lv'ontt?ly prom urns splayod have bccr? redacod by year est mated tax :redt 0151231130 Filter By Plan Type PPO HMO EPO Plan Features CSR Eligible I'll: lees cost sharing 'ecuctlors (owe' out-ci-pocket HSA Compatible Cr. 32 asec With .3 Hull". Savings Acmar?t Metal Platinum: hlghes: orem uws, lowest cut-o?- oocket costs Gold: higher p'e~iams. O'hef Dal-Ol-pOE (El (0515 Silver: lower premlums, ?acetate out-oI-pccket (0515 Bronze: lowest orem socket coats Yearly $499 and under $500 to $999 vn (7/100 Sort By Tola Exoerse Estimate ADD TO CART l .j GOLD I?lor?l?lly P'err' urrt P'Ill'dl?y Carr: Vl?jllb Get'er-g D'agb Yca'l'; all: lu-lal Lxuvrta?; LEI 'Ildl'.? Qaa l'y Hal 'lg COMPARE blu l? $169.10 after 511?: tax c'edlt Ypa pay 525 Yua pay 515 I-trlt Am. Lav-'5' I VIEW DETAIL ADD TO CART e@ a ?l.iG 'l GOLD P'urr ml P'Ill'dl?y Carr: \llb'll': U'agb Yua'ly all: IDIJI Lxuc'ltm 'llalv: {Jaa i?y Hal 'lg COMPARE l-?Ilo 52?864 after tax Yca pay $25 Ypa pay 515 5U llh'; t-trlt Am. vl Average Qua la'arl: VIEW DETAIL Local Help HEALTH PLANS ADD TO CART F. (9 Health Net' le?ll'll?y Pr "td'y? Car-'3 :15 Gem." l; Drugs "?car ?1 Hatlr?g COMPARE .: HU 4N3 $230 47 a?ter 3123 CC tax creclt You pay $le'. Apply Aycragl.? VIEW DETAIL ADD TO CART F. mun mnuwmr .: ~llt?C? pm at?? Vic'll'lly l-?r "ld'y' Car?: is Gu'tp' Drug-s "?L?ar 'v Dcuactlt I: prel?w Hallr'g COMPARE Appendix - 16 of 17 -llt?C 5228 78 a?ter 3123 CC ta): mean You pay $25 You pay 515 Nu." Apply Ayeragu VIEW DETAIL Logln Espal'lolv DENTAL PLANS CART 0 ADD TO CART . i HDMAMNY Cl I: COLD Prelrl arr? P':'llary Ca'c Vs I: Gewerlc Drag: Yua' Scalp-?lth: lpia Ouallty Hall'lg $211.23 alte' 3' 2.1 tax Zr-EdlSLI Ambl'u Average it it COMPARE VIEW DETAIL ADD TO CART 6?7 Health Net' 3 .IHIJE ij COLD PPO Prelrl 'Jrr' Pvmary Ca'u V: I: Ge'lmlu Drag: lpia Lap-cast: Ou allf'; Hall'lg COMPARE $248.54 alte' 3' 2: CO tax :redl?. You pay $25 You pay 5?13 $3 33 szpl'u Average (.?aal ly r? Iatpre VIEW DETAIL Case 3:17-cv-05895-VC Document 76-3 Filed 10/25/17 Page 17 of 17 culvouu ":1.qu Us: Platinum: highest stem u~s, lowest cut-o?- oocket costs Gold: higher p'e"'iam5. o'her cat-olvpocwt costs Silver: lower premiums, ?ocerate out-ol-pctket (0515 Bronze: Icwest orem u~s, oocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company Blue Shield Health Net Health Net Kaiser LA Care Molina Health Care Oscar Health Plan Quality Rating Application Home I FAQs UvoChat COMPARE VIEW DETAIL ADD TO CART blue GOLD FBIO I?lor?l?rly P'err' u'n 52?864 after 512?: tax meant Carr: Yua pa" $25 Goren D'agb Yua pay 515 WM, $0 Lxuc'liv: le 'rral?: Av?e'agc 0de l'y Hal ?g 'C?Lnd Ham-a l'l a'urt: COMPARE VIEW DETAIL ADD TO CART r: GOLD I?lor'l?rly P'urr u"1 $252.33 after tax year: P'Ill'dl?y Carr: \ll'a'll'a Yca pay $25 Govern D'agb Yua pay 515 5U ADP lulal Lxuc'ltm 'nalv: Qua ly Hal 'Ig ll g'rcr - COMPARE VIEW DETAIL Burl bu'mr an, L1 Qua ?at 2 ur'rrl; for hob 1 -800-787-6921 Find Local Help COMPARE VIEW DETAIL ADD TO CART F. . A: NJ Hit?: 33.? ?Au?rl'lly P'c'nIL-rr 5228 T8 a?ter 3123 CC tax crecrt Pr "ia'y? Car-'3 :15 You pay $25 Go'm' t; Drugs You pay SI 5 "car 1 I: ?51 luta Oaalrly Hutir?g Average COMPARE VIEW DETAIL ADD TO CART F. blue 3' Hl_l PFC 33-3 PFC Vic'rl'lly P'c'nlurl 252 72 a?ter 3123 CC tax crecrt l-?r "ra'y Car?: a ?35 You $25 Go'tu' Drugs Vou pay $15 Qr' -, -- . JUJLJL $1an luta prcr?w ll - 3 Oaalrly Halir'g COMPARE VIEW DETAIL Appendix - 17 of 17 Logln Espa?olv COMPARE VIEW DETAIL ADD TO CART a? Health Net? 3 :21le . COLD PPO Prom urr~ $248.54 3'23 CO tax dl'. P'nrary Ca'c V5 You pay 525 In.? It: Generic Duglufa Lupe-15c A?V'?dgg ly Hu'yru? r? lulu-?2 Quality Hali'ig COMPARE VIEW DETAIL ADD TO CART OSCOI I: -.1 COLD EPO lvlc-r'tl'w' Prom urr' $276.82 alte' 5 2: CO tax :redr?. Ca'u You pay $75 Generic Dug: You pay 5?5 5U SLI Yul luia . '1 - . . Qualify Rali'ig HJJ u, Lituo COMPARE VIEW DETAIL Case 3:17-cv-05895-VC Document 76-4 Filed 10/25/17 Page 1 of 11 State Regulators Have Improved Health Care Options for Lower-Income Consumers For a 50 year old living in Sacramento who earns 175% of the federal poverty level: Out-of-Pocket Monthly Premiums in 2017 Bronze: Out-of-Pocket Monthly Premiums in 2018 $1 Consumer Savings Per Month $1 Consumer pays the same price $48 If Consumer Switches to Lowest-Priced Silver, She Saves $10 (Lowest-priced plan in 2018) Silver: $58 $93 Gold:* (Most-popular plan in 2017) If Consumer Keeps Same Silver, She Pays $35 More $68 Consumer Saves $51 $119 Monthly Tax Credit in 2017 Monthly Tax Credit in 2018 $503 $575 *Consumers under 200% of the federal poverty line should rarely, if ever, purchase gold plans, because these consumers will pay less in additional costs (co-payments, deductibles, and co-insurance) by selecting a silver plan that provides cost-sharing reduction benefits. (Remember, these cost-sharing reduction benefits are only available on silver plans.) Appendix D - 1 of 11 Case 3:17-cv-05895-VC Document 76-4 Filed 10/25/17 Page 2 of 11 CHI for h? Find covulo Qumran?; Home FAQS Chat 1-800-787-6921 Local Help Log In I Espa?ol PREVIEW PLANS TELL US A LITTLE BIT ABOUT YOURSELF. Your information will help us ?nd out ifyou qualify for help paying for health coverage. Coverage Year: 20" 7 What is your Zip Code? 95843 What is your total income per year? $20790 1) How many people are in your household? 1 Enter the age of each person in your household, and tell us if they need coverage. Age of Head of Household 50 4 Needs Coverage? Is anyone in your household pregnant? Yes Is anyone in your household blind or disabled? Yes Back 300 My Results Appendix - 2 of 11 1-800-787-6921 Local Help 23x53: Application Home mocha Find ca'b'hdp Logln Espanoiv MY OPTIONS Here is what you told us: Zip Code: 95843 Total household income: $20,790 Household members: 1 Age of Head of Household: 50 Years I Needs Coverage? Household Includes: Pregnant Blind or Disabled Based on what you told us, here is what you may qualify for: Lower Premium It looks like you may qualify for a tax credit to lower your premium. Lower Out of Pocket Costs It looks like you may qualify for cost-shanng reductions. These will reduce the cost when you access care. To use cost-shanng reductions you must enroll in a Silver level plan. More Information Preview Plane These results are only an estimate. You will need to complete an application. Back Apply Now Appendix - 3 of 11 Find LocalHelpl Logln Espa?olv CALIFORNIA 1-800-787-6921 Application Home FAQs leeChat Back to prele'enees HEALTN PLANS DENTAL PLANS CART 0 9 plans for 1 adult in ZIP code 95843. Coverage could start as early as 01/015201 7. premiums displayed have been reduced by your estimated tax credit 01 $503.00 1 Filter By Plan Type HMO EPO PPO Plan Features CSR Eligible Includes cost sharing reductions (lower out-ot-pocket costs) HSA Compatible Can be used with a Health Sayings Account Metal Tier Platinum: highest premiums, lowest out of pocket costs Gold: higher premiums, lower out of pocket costs Silver: lower premiums, moderate out of pocket costs Bronze: lowest premiums. highest out of- pocket costs Yearly Deductible $499 and under $500 to $999 so" By Premium (low to high) ADD TO CART . i 3 PFRMANENTF Barge HMO BRONZE H30 Premium Primary Care ViSits Drugs Yearly Deducticle Total Expense Estin?ate ity Rat ng COMPARE $1 00 a'ter $406.02 tax credit You pay $75 You pay 100? a 36300 $500 v, Jay Applyi Lower I VIEW DETAIL ADD TO CART Western Health? . Advantage 3' B'Jr?ze BRONZE Premium Primary Care ViSits Gene'ic Drugs Yearly Dedu-ztic-le Total Expense Estirr ate ity Rat ng COMPARE 45A $1 15 a'ter 54 19.60 tax credit You pay 40": You pay 40": $4800 l\L?l Applyi Lower I tit?t VIEW DETAIL ADD TO CART . i Eh; EC BRONZE Premium Prmary Care Visns Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE HSA Mle $1.00 alter $409 3f tax credit You pay 40?vluv Acu?yf Lower I i VIEW DETAIL ADD TO CART A ithe I Blurflluu B'Jr'ze (ill ECO BRONZE EPO Premium Prmary Care Visns Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE Appendix - 4 of 11 $1.25 alter $462 16 tax credit You pay $75 You pay 100": 5633-3 55"" i?cla?v No! Aubry? Lower I VIEW DETAIL ADD TO CART Western Health" Advantage 3' *ize BRONZE HMO Moothly Premium Primary Care ViSits Generic Drugs Year Deductic-le lelal Expense Estirr ate ity Rating COMPARE Si 12 a?ter $463.69 tax credit You pay $75 You pay 100C 3 $6300 2 $500 he! Applyi Lower I i i if: "if? VIEW DETAIL ADD TO CART Anthem nlud?nm Burg-3 (ill EEO BRONZE Moothly Premium Primary Care ViSits Generic Drugs Year Deductiole Total Expense Eslirr ate ity Rating COMPARE EPO $1 27 a'ter $452.64 tax credit You pay 40?: You pay $4800 gl-i?ay l\L?l Applyi Lower I VIEW DETAIL Find Local Help CALIFORNIA 1 787 1 Log In Espa?ol Application Home FAQs leeChat Back to prele'enees HEALTN PLANS DENTAL PLANS CART 0 7 plans for 1 adult in ZIP code 95843. Coverage could start as early as 01/015201 7. premiums displayed have been reduced by your estimated tax credit ol $503.00 a Filter By Plan Type HMO EPO PPO Plan Features CSR Eligible lncludes cost sharing reductions (lower out-ot-pocket costs) HSA Compatible Can be used with a Health Sayings Account Metal Tier Platinum: highest premiums, lowest out of pocket costs Gold: higher premiums, lower out of pocket costs Silver: lower premiums, moderate out of pocket costs Bronze: lowest premiums. highest out of- pocket costs Yearly Deductible $499 and under $500 to $999 so" By Premium (low to high) ADD TO CART . i 3 PFRMANENTF 8? SILVER Premium Primary Care ViSits Drugs Yearly Deducticle Iotal Expense Estin?ate ity Rat ng COMPARE $5824 a'ter sac-3.00 tax credit You pay $10 You pay $5 $650 $50 Applyi Lower I VIEW DETAIL ADD TO CART blue El 8? P50 SILVER Premium Primary Care Vi5its Gene'ic Drugs Yearly Deductiole Iotal Expense Estirr ate Qua ity Rat ng COMPARE 9P0 $166 32 a?tor $50300 tax credit You pay $10 You pay $5 $650 550 he! Applyi Average if? 1: 71? VIEW DETAIL ADD TO CART Western Health Advantage 3' ?3 :27 SILVER Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble lota Expense Estimate Quality Rating COMPARE Mvio $92 55 alter $503 00 tax credit You pay $10 You pay $5 5653 l?vluv .Au'u?jvf Lower titt? VIEW DETAIL ADD TO CART (9 Health Net' SILVER Premium Prmary Care ViSits Drugs Yearly Deduct ble Tota Expense Estimate Quality Rating COMPARE Appendix - 5 of 11 MO $197.57 alter $503 00 tax credit You pay $10 You pay $5 565?.) $59 l?i'luy Auu?yj Averaqe i IT: 132?: VIEW DETAIL ADD TO CART Anthem 23 Ell'hj? ?37 EPO ii" VS: Moothly Premium Primary Care ViSits Generic Drugs Year Deductic-le lotal Expense Estirr ate ity Rating COMPARE EPO 8155 07 a?ter $503.00 tax credit You pay $10 You pay $5 $550 9 $50 alu?uy he! Applyi Average tt??t VIEW DETAIL ADD TO CART blue E-ilv-jr 8? l? li'lO SILVER HMO Moothly Premium Primary Care ViSits Oenenc Drugs Year Deductiole lotal Expense Estirr ate ity Rat no COMPARE $212 57 a?tor credit You pay $10 You pay $5 $650 $50 allay hut Applyi Average Ity Rating in ?uture VIEW DETAIL Find Local Help cnironuu 1 787 1 Log In Espa?ol Application Home FAQs Uvecnat Back to prele'ences HEALTN PLANS DENTAL PLANS CART 0 8 plans for 1 adult in ZIP code 95843. Coverage could start as early as 01/"01l2017. premiums displayed have been reduced by your estimated tax credit ol $503.00 Filter By so" By Premium (low to high) Plan Type ADD TO CART ADD TO CART 2 ADD TO CART HMO . 0 Western Healrh' EPO i 2 Prkumrmr i 2 Adv-muse 3' PPO (3.: 1 8C- (Solo 81'; '1 Bl} HMO GOLD mm 60.0 HMO Plan Features Premium $11854 Premium 5147,43 Moothly Premium 5212 24 a'ter sac-3.00 tax credit alter $503 00 tax :reart a?ter $503.00 tax CSR El'g'ble ?(?1095 l?ri'nary Care VISils You pay $30 Prmary Care You pay $30 P'Imary Care You pay $30 cost sharing reductions Drugs You pay $1 5 Generic Drugs You pay $15 Drugs You pay $1 5 (lower out-ol-pocket costsYearly Deducticle Vim}, Mt Apply: Yearly Deducl (\?df?ut Aggy) Year Deductic-le in,? My Apply! HSA com atible Can be lelal Expense I Iota Expense lelal Expense I Estrn?ale erage Estimate Averaqe erage used With a Health Sayings Account rty Rat no i Oualrty Rating i rty Rating it if: if: Metal Tier COMPARE VIEW DETAIL COMPARE VIEW DETAIL COMPARE VIEW DETAIL Platinum: highest premiums, lowest out of ADD TO CART ADD TO CART ADD TO CART pocket costs Gold: hrgher premiums, lower out of pocket costs Silver: lower premiums, moderate out of pocket costs Bronze: lowest premiums. highest out of- pocket costs Yearly Deductible $499 and under $500 to $999 blue 83 P50 GOLD Premium Primary Care Vi5ils Gene'Ic Drugs Yearly Deductiole lolal Exoense PPO $327 94 a?ter sac-3,00 tax credit You pay $he! Apply: Eslirrale Average lty Rat no if: 1: 7i: COMPARE VIEW DETAIL tthe I nluKim Gold 82' EPO, 2m MSP GOLD Premium Prmary Care VISils Generic Drugs Yearly Deduct ble Tota Expense Estlmale Oualrty Hating COMPARE Appendix - 6 of 11 EPO $328.78 alter $503 00 tax small You pay $30 You pay 515 en 5" r??zly K12): Averaqe i IT: 132?: VIEW DETAIL blue 60.0 HMO Premium Primary Care VISits Oenenc Drugs Year Deductrole lelal Expense tty Rat ng COMPARE $364 90 a?tor 5503.00 lax crodrl You pay $30 You pay $15 $0 $0 allay hut Apply-1 Average Ily Ratlnq in ?uture VIEW DETAIL Case 3:17-cv-05895-VC Document 76-4 Filed 10/25/17 Page 7 of 11 CHI for h? Find covulo Qumran?; Home FAQS Chat 1-800-787-6921 Local Help Log In I Espa?ol PREVIEW PLANS TELL US A LITTLE BIT ABOUT YOURSELF. Your information will help us ?nd out ifyou qualify for help paying for health coverage. Coverage Year: 20" 8 What is your Zip Code? 95843 What is your total income per year? $21105 1) How many people are in your household? 1 Enter the age of each person in your household, and tell us if they need coverage. Age of Head of Household 50 4 Needs Coverage? Is anyone in your household pregnant? Yes Is anyone in your household blind or disabled? Yes Back 300 My Results Appendix - 7 of 11 1-800-787-6921 Local Help 23x53: Application Home mocha Find ca'b'hdp Logln Espanoiv MY OPTIONS Here is what you told us: Zip Code: 95843 Total household income: $21,105 Household members: 1 Age of Head of Household: 50 Years I Needs Coverage? Household Includes: Pregnant Blind or Disabled Based on what you told us, here is what you may qualify for: Lower Premium It looks like you may qualify for a tax credit to lower your premium. Lower Out of Pocket Costs It looks like you may qualify for cost-shanng reductions. These will reduce the cost when you access care. To use cost-shanng reductions you must enroll in a Silver level plan. More Information Preview Plane These results are only an estimate. You will need to complete an application. Back Apply Now Appendix - 8 of 11 cnivonuu Back to prele'ences Application Home FAQs leeChat 7 plans for 1 adult in ZIP code 95843. Coverage could start as early as 1-800-787-6921 Find Local Help premiums displayed have been reduced by your estimated tax credit ol $575.00 Filter By Plan Type HMO PPO Plan Features CSR Eligible Includes cost sharing reductions (lower out-of-pocket costs) HSA Compatible Can be used With a Health Sayings Account Metal Tier Platinum: highest premiums. lowest out of pocket costs Gold: higher premiums. lower out of pocket costs Silver: lower premiums, moderate out of pocket costs Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 so" By Premium (low to high) ADD TO CART . i 3 Barr?s-3 in} BRONZE Premium I?rimary Care ViSils Drugs Yearly Deductiole letal Expense Estin?ate ity Rat ng COMPARE BSA $1 00 a'ter $432. 1'6 tax credit You pay You pay 40": $4800 Ju?ay Applyi Lower I VIEW DETAIL ADD TO CART HEALTH PLANS ADD TO CART . i {d2 HMO Premium Prmary Care Visns Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE $1.00 alter $433 891ax credit You pay $75 You pay 100": $6303 l?vluv Acu?yf Lower i VIEW DETAIL ADD TO CART Logln Espa?olv DENTAL PLANS CART 0 ADD TO CART (9 Health Net? Bronze Ell?:l" .ecCa'e BRONZE PRO Moothly Premium Primary Care ViSits Generic Drugs Year Deductic-le lolal Expense Eslirr ate ity Rating COMPARE 81 00 a?ter $511.08 tax cred You pay $75 You pay 100C 3 $5300 2 $500 away he! Applyi Lower II ily Rating in ?uture VIEW DETAIL ADD TO CART Wettern Health. Advantage 3' Weatern Health, Advantage 3' Erma: v31} MCI-I: blue (HZ- EEO BRONZE l-?Ii?O Premium Primary Care Vi5ils Gene'ic Drugs Yearly Deductiole Ielal Expense Estirr ate Qua ity Rat rig COMPARE $1 00 a?tor $515,15th credit You pay $75 You pay 100: 3 $6300 1' $500 he! Applyi Lower II 1: 71? VIEW DETAIL BRONZE Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE Appendix - 9 of 11 HSA HMO $1.00 alter $532 41 iax credit You pay 40? a You pay 40? 3 l?t?lzly Lower VIEW DETAIL Moothly Premium Primary Care Oenenc Drugs Year Deductiole letal Expense Eslirr ate Ouaity Rating COMPARE FSA $42.51 a?tor Sbi'bL-C- tax credit You pay You pay 40?: $4800 Apply-i Average if: VIEW DETAIL Back to prele'enees Application Home FAQs leeChat 5 plans for 1 adult in ZIP code 95843. Coverage c0u d start as early as 1-800-787-6921 premiums displayed have been reduced by your estimated tax credit ol $575.00 a Filter By Plan Type HMO PPO Plan Features CSR Eligible Includes cost sharing reductions (lower out-of-pocket costs) HSA Compatible Can be used With a Health Savings Account Metal Tier Platinum: highest premiums. lowest out of pocket costs Gold: higher premiums. lower out of pocket costs Silver: lower premiums, moderate out of pocket (0515 Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 so? By Premium {low to high) ADD TO CART blue 3 ver 8? SILVER Premium Primary Care Visrts Gene'rc D'ugs Yearly Iotal Expense Estin?ate rty Rat ng COMPARE $4799 a?ter $515.00 tax credit You pay $10 You pay $5 $650 5 $50 Applyi Lower I rty Hatrnq in ?ature VIEW DETAIL ADD TO CART (19 Health Net' 3 yer r3." E'Il'ul? .-2CC;ir-: SILVER Premium Primary Care Visrts Gene'rc D'ugs Yearly Iotal Exoense Estirrate ity Rat ng COMPARE DPO $241 36 a?ter 5515,00 tax credit You pay $10 You pay $5 $650 $50 Ju?ay Applyi Average Ity Hatrnq in ?ature VIEW DETAIL SILVER Premium l?r mary Care ViSits Generic Drugs Yearly Deduct ble Iota Expense Estimate Oual ty Hating COMPARE Local Help HEALTH PLANS ADD TO CART alter Sol-?$653 $53 Act; Lower titiifr VIEW DETAIL ADD TO CART blue 3 if," EPCI SILVER Premium Pr mary Care ViSits Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE Appendix - 10 of 11 P90 $284.08 alter Sin$653 553 Why Act; y: Averaqe ii: VIEW DETAIL Logln Espa?olv DENTAL PLANS CART 0 ADD TO CART Western Health Advantage 9' ?E-ilxr-L 8? I- MO SILVER HUD Premium Primary Care Visits Generic Drugs Year Deductic-le l-atal Exaense Estrn? ate ity Rat ng COMPARE $203 36 a?tei swbeo tax credit You pay $10 You pay 55 $650 3 $50 l\Ll Applyi Average tii?? VIEW DETAIL cnivonuu Back to prele'ences Application Home FAQs leeChat 6 plans for 1 adult in ZIP code 95843. Coverage could start as early as 1-800-787-6921 premiums displayed have been reduced by your estimated tax credit ol $575.00 Filter By Plan Type HMO PPO Plan Features CSR Eligible Includes cost sharing reductions (lower out-of-pocket costs) HSA Compatible Can be used With a Health Sayings Account Metal Tier Platinum: highest premiums. lowest out of pocket costs Gold: higher premiums. lower out of pocket costs Silver: lower premiums, moderate out of pocket costs Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 so" By Promium (low to high) ADD TO CART . i 3 (3.: 1 8C- lr?JC HMO Premium I?rimary Care ViSits Drugs Yearly Deducticle Ietal Expense Estin?ate ity Rat ng COMPARE $6811 a'ter $515.00 tax credit You pay $Applyi Lower I VIEW DETAIL ADD TO CART Wettern Health Local Help HEALTH PLANS ADD TO CART . i (331C :33 GOLD Premium Prmary Care Visns Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE 5101,86 alter 35,95 00 tax credit You pay $l?vluv Acu?yf Averaqe tittifr VIEW DETAIL ADD TO CART Logln Espa?olv DENTAL PLANS CART 0 ADD TO CART blue Qt? Gale r23 HMO HMO Moothly Premium Primary Care ViSits Generic Drugs Year Deductic-le lolal Expense Estirr ate ity Rating COMPARE $161 32 a?ter tax credit You pay $away he! Applyi Average ily Rating in ?uture VIEW DETAIL ADD TO CART Advantage 3" Gr; '1 8C- (9 Health Net' Gr; :1 EZI E?ll?ill? P90 blue Gr: :l 82' GO-D HMO Premium Primary Care Vi5ils Gene'ic Drugs Yearly Deductiole Ietal Expense Estirr ate Qua ity Rat rig COMPARE $218 98 a?ter tax credit You pay $he! Applyi Average tittiri? VIEW DETAIL GOLD Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE Appendix - 11 of 11 PPO $365.48 alter sat-'5 00 tax credit You pay $r?t'lzly KL): nghC' Ii Oual 1y Hating future VIEW DETAIL GOLD Moothly Premium Primary Care Oenenc Drugs Year Deductiole letal Expense PPO $411.48 a?ter Sbi'bL-C- tax credit You pay $25 You pay $15 $0 $0 Apply-i Eslirrate Higher . Quality Rating if: COMPARE VIEW DETAIL Case 3:17-cv-05895-VC Document 76-5 Filed 10/25/17 Page 1 of 11 State Regulators Have Improved Health Care Options for Lower-Income Consumers For a family of four living in Sacramento that earns 275% of the federal poverty level: (The two adults are 40 years old, and two children are 10 and 8 years old) Out-of-Pocket Monthly Premiums in 2017 Bronze:†† Out-of-Pocket Monthly Premiums in 2018 Consumer Savings Per Month $4 Family Saves $93 $97 $403 Silver: $427 Family Can Switch to Lowest-Priced Silver and Save $24 (Lowest-priced plan in 2018) $507 If Family Keeps Same Plan, They Pay $80 More (Most-popular plan in 2017) Family Can Switch to Gold for an Additional $22 Gold: $556 $449 Family Saves $107 Monthly Tax Credit in 2017 Monthly Tax Credit in 2018 $775 $1022 †† During 2017 open enrollment, about 42 percent of consumers between 250% and 400% of the federal poverty level purchased a bronze plan, about 43 percent purchased a silver plan, and about 8 percent purchased gold plans. Covered California, Covered California Open Enrollment Profile, Statewide Cross Tabulations (2017), https://perma.cc/8VK8-T2P7. Appendix E - 1 of 11 Case 3:17-cv-05895-VC Document 76-5 Filed 10/25/17 Page 2 of 11 camornelp Find Local Help LOgln covnlo i3" Home FAQs Live Chat 1-800-787-6921 PREVIEW PLANS TELL US A LITTLE BIT ABOUT YOURSELF. Your information will help us ?nd out ifyou qualify for help paying for health coverage. Coverage Year: 20" 7 What is your Zip Code? 95843 What is your total income per year? $66825 1) How many people are in your household? 4 Enter the age of each person in your household, and tell us if they need coverage. Age of Head of Household 40 4 Needs Coverage? Age of Person 2 40 Needs Coverage? Age of Person 3 10 4 Needs Coverage? Age of Person 4 Bl Needs Coverage? Is anyone in your household pregnantanyone in your household blind or disabled? Back See My Results Appendix - 2 of 11 Cal for help Find ?mm 1-800-787-6921 Local Help Logln Espa?olv MY OPTIONS Here is what you told us: Zip Code: 95843 Total household income: $66,825 Household members: 4 Age of Head of Household: 40 Years Needs Coverage? Age of Person 2: 40 Years 4 Needs Coverage? Age of Person 3: 10 Years I Needs Coverage? Age of Person 4: 8 Years I Needs Coverage? Household Includes: Pregnant Blind 0r Disabled Based on what you told us, here is what you may qualify for: You loyaliol?yfor: Lower Premium It looks like you may qualify for a tax credit to lower your premium. More Information Preview Plum These results are only an estimate. You will need to complete an application. Back Apply Now Appendix - 3 of 11 cnivonuu Application Home FAQs leeChat Cal for help 9 plans for 2 adults and 2 children in ZIP code 95843. Coverage c0uld start as early as O1i"01i'2017, 1-800-787-6921 Find premiums displayed have been reduced by your estimated tax credit of $775.00. Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used with a Health Sayings Account Metal Tier Platinum: highest premiums. lowest out of pocket costs Gold: higher premiums. lower out of pocket costs Silver: lower premiums. moderate out of pocket (OSIS Bronze: lowest premiums. highest out of, pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company Total Expense Estimate msut Ptkummrt E'o'ee HMO BRONZE Premium Primary Care ViSits Drugs Yearly DeduetIC-Ie Ietal Expense ate rty Rat ng COMPARE Local Help ADD TO CART $9692 a'ter 53/500 tax credit You pay 575 You pay 100c 3 $12600 i' $1000 Applyi Lower - VIEW DETAIL ADD TO CART . i PERMANENT Btu'tzvj {13 HEN: BRONZE Premium Prmary Care Visns Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE HSA Hle 5104,10 utter SHSUO tax credit You pay 40? 3 You pay 40? a $9638 I?t'lu'v Nut Auufy: Lower l- i A VIEW DETAIL ADD TO CART Anthem Flu-(Inn: Bring?: i-?J EPO BRONZE E90 Premium Primary Care ViSits Drugs Yearly DeduetIC-Ie Ietal Expense Estir?r? ate rty Rat ng COMPARE $217 72 a'ter Si'i'5.00 tax credit You pay $75 You pay 100c 2 312600 i' $1000 Applyi Lower . i i ii? 1C: 11? VIEW DETAIL ADD TO CART 49 Health Net' ADD TO CART Western Health, . Advantage 7" Bronx?:- BRONZE Premium Prmary Care Visns Generic Drugs Yearly Deduct ble iota Expense Estimate Quality Rating COMPARE we HMO 5220,72 utter Six": 00 tax credit You pay $75 You pay 100": 512600 l?t'lu'v Lower l- titt? VIEW DETAIL ADD TO CART hli re (F37 Appendix - 4 of 11 Logln Espa?olv ADD TO CART Bursa? [ill BRONZE Premium Primary Care ViSits Generic Drugs Year Deducttole letal Expense Estln" ate Ity Rating COMPARE web: are PSA EPO $197 38 a?tei $115.00 tax credit You pay 40": You pay 40% $9600 -, lu?ay Nu! Appl yr Lower I tt??t VIEW DETAIL ADD TO CART Western Health, . Advantage t" Brit's-315'} BRONZE Premium Primary Care ViSits Generic Drugs Year Deduettole letal Expense Estln" ate ity Rating COMPARE $254 86 a?ler $115.00 tax credit You pay 40": You pay 40?: $9600 Nu! Applyi Lower - tt??t VIEW DETAIL ADD TO CART hli re (F17 cnivonuu Application Home FAQs leeChat Cal for help 7 plans for 2 adults and 2 children in ZIP code 95843. Coverage c0u d start as early as 01/015201? 1-800-787-6921 Find premiums displayed have been reduced by your estimated tax credit of $775.00. Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used With a Health Savings Account Metal Tier Platinum: highest premiums. lowest out of pocket costs Gold: higher premiums. lower out of pocket costs Silver: lower premiums. moderate out of pocket (0515 Bronze: lowest premiums. highest out of, pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over Company A nl. . so" By Total Expense Estimate ADD TO CART msut Ptkummrt Silver SILVER H240 Premium Primary Care ViSits Gene'ic D'ugs Yearly DeduetIC-Ie Ietal txoense ate My Hat ng COMPARE $427 28 a'ter 53/500 tax credit You pay 535 You pay $1 5 $5000 $500 Applyi Lower - VIEW DETAIL ADD TO CART blue El P50 SILVER Premium Prr'nary Care ViSits Gene'ic D'ugs Yearly Deductic-Ie Ietal Expense Estrn?ate ity Rat ng COMPARE 9P0 3658 84 a'ter tax credit You pay $35 You pay 515 $5000 $500 i. Applyi Average it?t? VIEW DETAIL ADD TO CART Anolmm A Local Help ADD TO CART Western Health, 4 Advantage '4 v] SILVER Premium I?rmary Cave Visns Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE ?3 NVO HMO $500.80 utter SHSUO tax credit You pay $35 You pay $15 551203 l?vlu'v Nu?. .Auufy: Lower l- titt? VIEW DETAIL ADD TO CART (9 Health Net? Sll'c-j SILVER Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE Appendix - 5 of 11 Mvto 5725,78 alter tax credit You pay $35 You pay S15 5538?.) Sbuc l?vluv Nu'. .A'u'u?yi Averaqe VIEW DETAIL Logln Espa?olv ADD TO CART Ell'hj' EP0 ii" ?33: Premium P'imary Care ViSits Generic Drugs Year Deducttole letal txoense Estln" ate Ity Rating COMPARE EPO $634 72 a?tor $115.00 tax credit You pay 535 You pay $1 5 $5000 $500 allay Applyi Average tt??t VIEW DETAIL ADD TO CART blue WHO SILVER HMO Meethly Premium Primary Care ViSits Generic Drugs Year Deduettc-le letal Expense Estrn? ate ity Rating COMPARE $757 92 a?tor 5/1500 tax credit You pay $35 You pay 515 $5000 5 $500 away he! Applyi Average Ity Rating in ?uture VIEW DETAIL Find Local Help Cal for help 1 -800-787-6921 cnivonuu Logln Espanolv Home FAQs leeChat 1 Back to preferences ?mm PLANS DENTAL PLANS CART 0 8 plans for 2 adults and 2 children in ZIP code 95843. Coverage could start as early as premiums displayed have been reduced by your estimated tax credit of $775.00 Filter By Plan Type HMO EPO PPO Plan Features HSA Compatible Can be used With a Health Savings Account Metal Tier Platinum: highest premiums. lowest out of pocket costs i" Gold: higher premiums. lower out of pocket costs Silver: lower premiums, moderate out of pocket costs Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to 5999 $1000 to 52499 52500110 54999 so" By Total Expense Estimate ADD TO CART . i 3 PFRMANENTF (3.: 1 8C- HMO Premium l?ri'nary Care ViSits Drugs Yearly Deductiole l-otal Expense Estin?ate ity Rat ng COMPARE $556 50 a'ter $115.00 tax credit You pay $Ju?ay Applyi Average VIEW DETAIL ADD TO CART blue Gr; 83 P50 GOLD Premium Primary Care Vi5its Generic Drugs Yearly Deductiole lotal Expense Estirr ate Qua ity Rat ng COMPARE PPO $1005.04 a?ter sneer: tax credit You pay $he! Applyi Average if? 1: 71? VIEW DETAIL ADD TO CART . i (331C :33 GOLD Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Iota Expense Estimate Quality Rating COMPARE also 5618,46 alter Si'r?b 00 tax credit You pay $l?vlav Asa?) Averaqe VIEW DETAIL ADD TO CART A ithe I nluKim Gold 82' EPO, 2m lle-P GOLD Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Tota Expense Estimate Quality Rating COMPARE Appendix - 6 of 11 EPO $1006 84 alter Sr'i?b 00 tax credit You pay $30 You pay 515 en 5" I?i?lzly AUUIV: Averaqe i IT: 132?: VIEW DETAIL ADD TO CART Western Health Advantage 3" Gr; '1 Bl} HMO Moothly Premium Primary Care ViSits Generic Drugs Year Deductic-le lotal Expense Estirr ate ity Rating COMPARE 8757 20 a?ter Sr'i'bL-U tax credit You pay $30 You pay $15 $0 $0 away he! Applyi Average i i if: if? VIEW DETAIL ADD TO CART blue l?lv-IO HMO Moothly Premium Primary Care ViSits Oenenc Drugs Year Deductiole l-otal Expense Estirr ate ity Rat no COMPARE $1084.24 a?ter tax credit You pay $30 You pay $15 $0 $0 l\L?t Applyi Average ity Rating in ?uture VIEW DETAIL Case 3:17-cv-05895-VC Document 76-5 Filed 10/25/17 Page 7 of 11 camornelp Find Local Help LOgln covnlo i3" Home FAQs Live Chat 1-800-787-6921 PREVIEW PLANS TELL US A LITTLE BIT ABOUT YOURSELF. Your information will help us ?nd out ifyou qualify for help paying for health coverage. Coverage Year: 20" 8 What is your Zip Code? 95843 What is your total income per year? $67650 1) How many people are in your household? 4 Enter the age of each person in your household, and tell us if they need coverage. Age of Head of Household 40 4 Needs Coverage? Age of Person 2 40 Needs Coverage? Age of Person 3 10 4 Needs Coverage? Age of Person 4 8 I Needs Coverage? Is anyone in your household pregnantanyone in your household blind or disabled Back See My Results Appendix - 7 of 11 Cal for help Find ?mm 1-800-787-6921 Local Help Logln Espa?olv MY OPTIONS Here is what you told us: Zip Code: 95843 Total household income: $67,650 Household members: 4 Age of Head of Household: 40 Years Needs Coverage? Age of Person 2: 40 Years 4 Needs Coverage? Age of Person 3: 10 Years I Needs Coverage? Age of Person 4: 8 Years I Needs Coverage? Household Includes: Pregnant Blind 0r Disabled Based on what you told us, here is what you may qualify for: You loyaliol?yfor: Lower Premium It looks like you may qualify for a tax credit to lower your premium. More Information Preview Plum These results are only an estimate. You will need to complete an application. Back Apply Now Appendix - 8 of 11 Find Local Help cautonuu 1-800-787-6921 Application Home FAQs leeChat I Logln Espanolv Back to prele'ences ?mm PLANS DENTAL PLANS CART 0 7 plans for 2 adults and 2 children in ZIP code 95843. Coverage could start as early as premiums displayed have been reduced by your estimated tax Credil ol 51.022 00 Filter By Plan Type HMO PPO Plan Features HSA Compatible Can be used With a Health Sayings Account Metal Tier Platinum: highest premiums. lowest outvof. pocket costs Gold: higher premiums. lower out of pocket costs Silver: lower premiums. moderate out of pocket COSTS Bronze: lowest premiums. highest out of, pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over so" By Promium (low to high) ADD TO CART . 3 B?jr?ze BRONZE Premium Primary Care ViSits Drugs Yearly Deductic-le letal Expense Estirr ate ity Rat ng COMPARE 48A S4 00 a'ter $988.34 tax ClC?dll You pay 40?: You pay 40": $9600 Applyi Lower I tiff": VIEW DETAIL ADD TO CART I Western Health. Advantage 3' 9'3"sz Ell HMO BRONZE Premium Primary Care VISIIS Drugs Yearly Dedu-ztic-le lotal Expense Estin? ate ity Rat ng COMPARE $158 86 a?ter $1022.00tax credit You pay $75 You pay 100? $12600 $1000 Ju?ay kc! Applyi Lower - i i i 1C: VIEW DETAIL ADD TO CART 2 . i Brena-2 {it HMO Premium Pr:mary Care Generic Drugs Yearly Deduct ble Tota Expense Estimate Quality Rating COMPARE $4.00 alter $990.94 tax credit You pay $75 You pay 100": $1262?) l?ivluy Aau?y) Lower tittifr VIEW DETAIL ADD TO CART Western Health. Advantage 3' Burn?: 63 BRONZE Premium Prmary Care Visns Generic Drugs Yearly Deduct ble Tota Expense Estimate Quality Plating COMPARE Appendix - 9 of 11 HSA PMO 5198,32 alter $1022 00 tax Credit You pay 40? 3 You pay 40? 3 $9630 l?i?ld'y Auu?y) Lower l- titt? VIEW DETAIL ADD TO CART a? Health Net' Bung-:- BRONZE FPO Moothly Premium Primary Care ViSits Generic Drugs Year Deductiole letal Expense ate ity Rat ng COMPARE 8149 S2 a?ter $1022.00 tax ClOdll You pay $75 You pay 100c 3 312600 $1000 Applyi Lower II Qua Ity Ratinq in ?uture VIEW DETAIL ADD TO CART blue Burr-3 [u BRONZE Premium Primary Care ViSIts Genen: Drugs Year Deduetlc-le l-olal Expense Eslirr ate ity Rating COMPARE 3 l?Dl?: PSA 9P0 8390 74 a?ter $1022.00 tax credit You pay 40": You pay 40": $9600 Ml Applyi Average i ii: if: VIEW DETAIL Find Local Help Cal for help 1 -800-787-6921 cnivouu Home FAQs leeChat Logln Espa?olv Back to prele'enees HEALTH PLANS DENTAL PLANS CART 0 5 plans for 2 adults and 2 children in ZIP code 95843. Coverage c0u d start as early as premiums displayed have been reduced by your estimated tax credit of $1,022 00 Filter By Plan Type HMO PPO Plan Features HSA Compatible Can be used a Health Account Metal Tier Platinum: hlghest so? By Premium {low to high) ADD TO CART blue Qt? 3 tier 73 Mle SILVER Premium l?rlrnary Care VISits Generic Drugs Yearly Dedu-ztic-lo lotal Expense 8403 28 a?ter $1022 tax credit You pay $35 You pay 515 $5000 S260 Apply: ADD TO CART 2 . i I PERMANENTT 3 w' SILVER Premium l?r mary Ca'c Generic Drugs Yearly Deduct ble Iota Expense ?3 we l4 MO 5506,86 ullcr $1022 00 tax credit You pay $35 You pay $15 $263 l?n'lzly ADD TO CART Western Health 3? Advantage 9' Hle SILVER HUD l?remlum Primary Care Oenenc D'ugs Year DeductIC-le total Expense 5758 74 a?ter $1022.00 tax You pay $35 You pay 315 $5000 5 $260 Apply-i premiums. ?me? out of Estimate Lower - Averaqe Average pocket costs Qua rty Rat ng 9:33, Hatinq In Oualty Rating Gold: hlgher COMPARE VIEW DETAIL COMPARE VIEW DETAIL COMPARE VIEW DETAIL lower out of pocket costs Silver: lower remlums. ADD TO CART 1! ADD TO CART moderate out of pocket costs (1'9 Health Net? ber Bronze: lowest premiums, highest out of a ver 0 ,ecear': lw ~Pu Pocket costs SILVER =Po SILVER P=>o Premium 5845 66 Premium $943.40 Yearly Deductible a?ter 51022 ec- tax alter 31022 no tax credit Lrecllt $499 and under Primary Care VISits You pay $35 Pr mary Care You pay $35 D'ugs You pay $1 5 Generic Drugs You pay $15 $500 to 5999 $1000 to $2499 $2500 to $4999 $5000 and over Yearly lotal Expense Estimate My Hat ng COMPARE $5000 .- 52w v. A?tppl yi Average Qua Hatinq in ?utUlD VIEW DETAIL Yearly Deduct ble Iota Expense Estlmate Oaal ty Hallng COMPARE Appendix - 10 of 11 5533?.) $261} I?ddy Apt; y: nghe' I- i i: VIEW DETAIL Find Local Help Cal for help 1 -800-787-6921 cnuronuu Home FAQs leeChat I Logln Espa?olv Back to preferences ?mm PLANS DENTAL PLANS CART 0 6 plans for 2 adults and 2 children in ZIP code 95843. Coverage could start as early as premiums displayed have been reduced by your estimated tax credit ol $1,022 00 Filter By Plan Type HMO PPO Plan Features HSA Compatible Can be used a Health Sayings Account Metal Tier Platinum: hrghest premiums. lowest out of pocket costs Gold: hrgher premiums. lower out of pocket costs Silver: lower premiums. moderate out of pocket (0515 Bronze: lowest premiums. highest out of pocket costs Yearly Deductible $499 and under $500 to $999 $1000 to $2499 $2500 to $4999 $5000 and over so" By Premium (low to high) ADD TO CART . i 3 PFRMANENTF (3.: 1 8C- HMO Premium Primary Care Vi5its Genc'ic Drugs Yearly letal Expense Estirr? ate ity Rat rig COMPARE $449 28 a'ter $1022 00 tax credit You pay $he! Applyi Lower ll VIEW DETAIL ADD TO CART ADD TO CART . i (331C :33 GOLD Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Tota Expense Estrmate Oualyty Rating COMPARE also $526.52 alter $1022 00 tax :rC?main-J: Aupfyi Averaqe VIEW DETAIL ADD TO CART ADD TO CART blue r23 HMO HMO Moothly Premium Primary Care VISits Genenc Drugs Year Deductiele letal txoense Estirr ate rty Rat ng COMPARE 8662 56 a?ter $1 022.00 tax ClOdll You pay $25 You pay $15 $0 $0 Applyi Average Qua ity Ratlnq in ?ature VIEW DETAIL ADD TO CART I Western Health' Advantage 3' Gr; 1 Eli- a? Health Net' :1 ECI P50 blue 83 P50 HMO Premium l?rimary Care Vi5its Drugs Yearly Dedu-ztic-le letal txpense Estin? ate rty Rat ng COMPARE $794 48 a?ter 51022 00 tax credit You pay $Applyi Average VIEW DETAIL GOLD Premium Prmary Care ViSits Generic Drugs Yearly Deduct ble Iota Expense Estimate Oualty Hating COMPARE Appendix - 11 of 11 PPO $112962 alter $1022 00 tax Credit You pay $25 You pay 815 SC 53 i?vlay Nu'. Auu?yt Higher Oual 1y Hating luture VIEW DETAIL GOLD Premium Primary Care VISits Generic Drugs Year Deductic-le letal txpense ate ity Ratrng COMPARE PPO $123486 a'tor $1022.00 tax Ciedll You pay $alu'ay Net Applyi Higher - tt??t VIEW DETAIL