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California Health Insurance Plans for Individuals and Families

Income Levels for Medi-Cal and Tax Subsidies
If you fall within these income ranges your insurance will be low cost or at a reduced cost. Enhanced silver plans carry extra benefits.

Household Size Medi-Cal Enhanced Silver Plans Maximum
1 $1-$15,900 $15901-$28,725 $45,960
2 $1-$21,500 $21,501-$62,039 $62,040
3 $1-$27,000 $27,001-$78,119 $78,120
4 $1-$32,499 $32,500-$94,199 $94,200
5 $1-$38,047 $38,048-$110,279 $110,280

 

FAQ's about the Affordable Care Act
Q: What do I need to qualify for an individual or family health insurance plan?

A: This is probably the best feature of the new law. Everyone is now entitled to health insurance regardless of pre-existing conditions, and will pay the same amount as everyone else in their age group regardless of the quality of their health. In California the state has opted not to discriminate against smokers, even though the national law allows a 50% rate-up. So the plans are completely anti-discriminatory.


Q: What will happen if I don't get coverage this year, or the following years?

A: Every man, woman, and child who is a citizen, and under the age of 65 are supposed to have health insurance in 2014 as part of the "individual mandate" held up by the Supreme Court (except Native Americans and Eskimos). The penalties at first are modest, but go up every year. The penalties are assessed per family member, so if you have a family of 4 you will pay the individual penalty times 4, or an annually increasing percentage of your income whichever is greater.


Q: Is there a waiting period for pre-existing conditions?

A: As long as you apply during open-enrollment there is no pre-existing condition clause with any new health plan. Your can use your full coverage from the day your are approved.


Q: How much does individual insurance cost?

A: That depends on what type of coverage you want, and which plan you select. The new plans are standardized so it's easier to select a plan (although there is a lot less choice). There are 5 different types of plans available. One is just for people under 30 and is a "Catastrophic" plan, or very minimal coverage, but at the least expensive price. The other plans are arranged in metal tiers. There are called "platinum", "gold", "silver" and "bronze" plans. The highest tier has the most comprehensive coverage and the highest price. The price and coverage goes down about 10% for each metal tier. There are subsidies available for individuals and families within certain income ranges, and free Medical for people who fall within those ranges to help make plans more affordable.


Q: What are health insurance subsidies?

A: Depending on your income range, you may qualify for free Medical coverage, or health insurance subsidies to significantly reduce your monthly premium. An individual can make as much as $46,000 per year, and a family of 4 could make as much as $94,000 per year and still qualify for subsidies.

Q: How do I determine my income for subsidies or Medical?

A: When you apply on the CoveredCA website you will be asked for your family income and family size. The income you would report on the site is your adjusted gross, or net income for every member of the household. That is typically line 38 of the form 1040 tax return. A few deductions are not allowed however, so check with your tax professional if you need help in determining your adjusted gross. The income you will report is your estimated income for the plan year. If you apply for coverage stating in 2014 for example, you would indicate the adjusted gross for that year. If you have a change in income you should report it as soon as possible to avoid having to pay back subsidies at the end of the tax year. It is better to estimate higher than lower if you can, or just receive the tax credit with your refund and not take the subsidy if you can.


Q: Can I get coverage if I am pregnant (or my wife)?

A: Yes, there are no longer pre-existing conditions on the health plans. You must apply during open-enrollment however to be guaranteed coverage.


Q: When is "open-enrollment"?

A: Initially it is from October 1st, 2013 to March 1st 2014. This period of time you can select any healthplan offered in your area without having to qualify based on your health.


Q: What is the difference between an HMO and a PPO?

A: A PPO is a Preferred Provider Organization, or a network of doctors who have agreed to receive certain amounts as payment in full for their services from an insurance carrier or network provider. The PPO allows self referral to specialists, and allows the insured to control their own medical decisions. An HMO is a Health Maintenance Organization, or a network of doctors who have agreed to accept a monthly payment from a provider organization to care for their assigned insured. With an HMO you use a Primary Care Physician who is responsible for your medical decisions and referrals. HMOs are very expensive in the individual market.


Q: What is a deductible and coinsurance?

A: A deductible is amount you have to satisfy for most covered services. There are often exceptions which often include fixed copayment amounts for doctor office visits, and prescription medications. Coinsurance is a percentage the insured pays after the deductible is satisfied with an additional amount this is a fixed dollar figure. The total of the deductible and co-insurance is your Maximum-Out-of-Pocket. After which the plan pays 100% of covered services. As an example if you had a deductible of $2000 and 30% coinsurance of an additional $3000 (a calendar year maximum of $5000) and a $30,000 medical bill you would pay $2000, plus 30% of $10,000 ($3,000) or basically the full $5000 maximum out-of-pocket. After $10,000 your bills would be covered in full.