California Health Insurance Guide
California Health Insurance Information, Resources and Access to Online Health Insurance Quotes
As a California resident you can choose from health insurance plans offered to individuals and groups by private insurance companies. You may also purchase individual and family coverage from participating private insurers through Covered California, the state-run exchange. If you are self-employed with no employees, you can also use the state exchange to purchase coverage. You may also be entitled to certain state and federal programs such as Medicaid, CHIP or Medicare.
California and the Patient Protection and Affordable Care Act of 2010
The Patient Protection and Affordable Care Act (also known as ObamaCare and the Affordable Care Act and referred to in this guide as ACA) became law in 2010. Provisions of the law have continued to be phased in following passage. As of January 1, 2014, most U.S. citizens and legal residents are required by law to have qualifying health care coverage or pay an annual tax penalty for every month they go without insurance. This is called the “individual mandate.” There is a grace period through March 31, 2014. Beginning in 2014, the penalty for not having qualifying coverage is $95 per adult and $47.50 per child or 1% of your taxable income, whichever is higher (up to $285 per family). The penalty increases annually through 2017 and beyond.
Individual Mandate Exemptions
You may be exempt from the individual mandate and tax penalties if:
- You have religious objections
- Are in the U.S. illegally
- Are in jail
- The cost of coverage exceeds 8% of your household income
- Your income is below 100% of the poverty level
- You have hardship waivers
- You are not covered for fewer than three months during the calendar year
About Covered California – The State Healthcare Exchange
Any legal California resident, except for legal minors, can buy healthcare coverage through Covered California. However, if you have access to affordable, qualifying coverage from another source such as an employer or government program, you may not qualify for financial assistance from Covered California. You can apply at Covered California online at www.CoveredCA.com, by calling 1-800-300-1506 or in person.
California Small Business Coverage If you own a small business in California (50 or fewer full-time-equivalent employees – FTEs), you can purchase qualifying coverage for your employees through SHOP, the Small Business Health Option Program or through a private broker or insurance agent. However, you may qualify for tax credits worth up to 50% of your premium costs if you use SHOP. Beginning in 2016, SHOP will be open to employers with up to 100 FTEs. Under the Employer Shared Responsibility provision of ACA, beginning in 2015, all employers with 50 or more FTEs must offer employees at least one plan that is ACA-compliant or face fines of $2,000 per employee.
ACA Standardized Benefits
Plans offered by private insurers may offer additional benefits and individual states may require additional benefits, but all qualifying plans must offer these 10 standardized essential benefits:
- Ambulatory patient service
- Emergency services*
- Maternity and newborn care*
- Mental health and substance use disorder services including behavioral health treatment*
- Prescription drugs*
- Rehabilitative and habilitative services and devices
- Preventive and wellness and chronic disease management for adults and children, including 100% coverage for some services*
- Pediatric service, including oral and vision care*
*Lifetime dollar limits on these essential health benefits have been eliminated.
California Additional Mandated Benefits
California currently mandates that the following benefits, which exceed ACA requirements, must be provided or offered by specified private providers authorized to sell health insurance within the state:
- Ambulance/emergency transportation – for individual and group plans regulated by DMHC and CDI
- Clinical trials – cancer trials - for individual and group plans regulated by DMHC and CDI
- Coverage for effects of diethylstilbestrol - for individual and group plans regulated by DMHC and CDI
- Diabetes care management – education, management and treatment - for individual and group plans regulated by DMHC and CDI
- Durable medical equipment – laryngectomy-assistive devices - for individual and group plans regulated by DMHC and CDI
- Hospice services - for individual and group plans regulated by DMHC and CDI
- Mastectomy-related coverage – for mastectomies and lymph node dissections - for individual and group plans regulated by DMHC and CDI
- Off-label prescription drugs - for individual and group plans regulated by DMHC and CDI
- Organ transplants – for persons with HIV - for individual and group plans regulated by DMHC and CDI
- Other cancer screenings – in addition to those mandated by ACA - for individual and group plans regulated by DMHC and CDI
- Prescription drug coverage – pain management for terminally ill, pedicatric asthma management, and previously prescribed prescription drugs - for individual and group plans regulated by DMHC and CDI
- Reconstructive surgery - for individual and group plans regulated by DMHC and CDI
- Treat for TMJ disorders – surgical procedures - for individual and group plans regulated by DMHC and CDI
California Available Standardized Plans
To help you more easily compare costs and benefits, ACA designates that all qualifying plans be one of four metals: Bronze, Silver, Gold and Platinum. Each is based on the average amount of healthcare costs the plan will cover shown as a percentage of what is covered by your insurance company and what is paid for by you. All insurers participating in the federal or a state healthcare exchange must offer , at minimum, Silver and Gold plans. All metal plans have a shared maximum out-of-pocket amount that you can be charged in any calendar year.
|Metal Plan||Insurer Pays||You Pay|
In addition, if you are under 30 or meet the criteria for a hardship exemption, you can purchase a catastrophic plan that is compliant with ACA requirements.
Premiums charged for any of the qualifying metal plans may be based on:
- Your age
- Tobacco use
- Where you live - determined by rating area
- The number of family members enrolling with you
Under ACA, no one can be denied coverage or charged significantly higher premiums because of past health history (pre-existing conditions) or gender. There can be no look-back or waiting periods imposed. Policies are effective on issue. All coverage is renewable, if you choose to renew it. Plans can only be canceled for non-payment of premiums or fraud. The guaranteed issue provision applies to all non-grandfathered plans.
ACA Financial Assistance
You may qualify for financial assistance in the form of tax credits to help with monthly premiums and subsidies to help with out-of-pocket costs.
- Tax credits can be applied to any of the four metal plans to lower your monthly premiums. They are paid directly to your insurance provider by the federal government. Your tax credit is based on your estimated income for the calendar year, in advance of filing your federal return. Note that if your actual income exceeds the eligibility limit, you will have to reimburse the government for the difference. Tax credits are only available to California residents who purchase coverage from Covered California.
- Subsidies to help California residents with out-of-pocket expenses such as copayments are only available for Silver plans purchased through Covered California and are only offered to those who earn up to 250% of the federal poverty level.
The following types of health insurance plans are available in California for individuals and families. They may be purchased through private providers or providers participating in the state exchange.
- Preferred Provider Organizations (PPOs)
You have access to a network of healthcare providers participating in your selected PPO. You do not have to select a Primary Care Physician or obtain a referral to see any in-network provider. Some PPOs may require that you meet a deductible before their portion of the coverage begins.
- Health Maintenance Organizations (HMOs)
Most HMOs require you to select a Primary Care Physician to coordinate your healthcare and provide referrals to specialists. HMOs typically charge a fixed copayment for each doctor visit and other care provided. Depending on the HMO, there may be a low deductible or no deductible in addition to the copayments. All services must be obtained through the HMO’s network, unless otherwise stated in your plan.
- High-Deductible Health Plans with Health Savings Accounts (HDHP w/HSAs)
These plans give you more control over your out-of-pocket expenses by offering lower monthly premiums with higher deductibles. They are typically combined with HSAs that allow you to set aside interest-earning pretax funds (through your employer’s payroll deduction) or tax-deductible funds you deposit in a private account. These funds can be drawn on to cover your healthcare costs. Any interest accrued is tax-deferred and any unused funds can roll over from year to year. See your tax advisor for information specific to your situation.
- Flexible Spending Accounts (FSAs)
ACA provisions allow you to continue to make tax-free contributions up to $2,500 per year to an FSA. These can be used for out-of-pocket healthcare expenses not covered by your insurance plan. This includes many over-the-counter (OTC) preparations, devices and equipment as allowed by law. However, you will need to obtain a prescription for OTC items and submit an itemized receipt to qualify for the tax deduction.
California Healthcare Resources
Low- and no-cost healthcare for California residents include:
California Regulating Agencies and Insurance Information Resources
California Department of Insurance
Consumer Services Division, 300 South Spring Street, South Tower, Los Angeles, CA 90013
Department of Managed Health Care
Insurance Information Institute
110 William Street, New York, NY 10038
California Healthcare Exchange
Find local in person enrollment assistance
SHOP California – Healthcare Insurance for Small Businesses
Fast Facts About ObamaCare