Individual and Family Covered California Navigation
While California has a variety of health insurance companies and health plans offering coverage in the state, they are not all available in all regions of California. California is broken up into 19 regions where health plans are offered. Even within these regions, some health plans may only be available in certain zip codes.
Off-exchange health plans
You can purchase health insurance directly from the carrier, also known as “off-exchange”, or you can enroll in a health plan through Covered California. All of the plans offered through Covered California are also offered off-exchange at the same premium rates. Outside of Open Enrollment, which happens each autumn for the next calendar year, you can only enroll in a health plan with a qualifying event such as moving to California, birth of a child, marriage, divorce, or losing your health insurance coverage.
Several of the carriers will also offer similar metal tier level plans off-exchange, but with slightly different benefits and/or member cost sharing. The premiums for these similar metal tier off-exchange plans are comparable the Qualified Health Plans offered on- and off-exchange. Some carriers like Cigna and Sutter Health Plan only offer off-exchange health plans.
Qualified Health Plans
A Qualified Health Plan is one that meets both the requirements of the Affordable Care Act and Covered California. Only Qualified Health Plans offered through Covered California are eligible for the Premium Tax Credits or monthly subsidies. All Qualified Health Plans have the exact same benefits across all the carriers in the respective metal tier level. This means the office visit copayment for Silver plan will be exactly the same regardless of what health insurance company is offering the plan.
Health plans purchased directly from an insurance carrier, even if they are a Qualified Health Plan, are not eligible for the Premium Tax Credits. If you enroll through Covered California you can accept the monthly subsidy to reduce your health insurance premium (also known as Advance Premium Tax Credit) or you can reconcile your household income on your federal tax return and receive the Premium Tax Credit then.
Income restrictions
Be aware that Covered California has income conditions for receiving the Advance Premium Tax Credit monthly subsidies. If your household income is below 138% of the federal poverty level, you will only be eligible for Medi-Cal, California’s version of no cost Medicaid. If there are children 18 years old and younger in the household, incomes under 266% (in most counties) will make the adults eligible for the monthly subsidy, but the children will only be eligible for Medi-Cal. Children can be enrolled in health plans separately, either off-exchange or through Covered California, but they will not be eligible for the monthly subsidy to reduce the premiums.
An easy way to view the majority of health plans offered in the region where you live is to use the Covered California Shop and Compare Tool. The tool will provide the current monthly premium for each plan. It won’t, however, indicate the off-exchange plans that may also be available to you. It also won’t tell you which doctors and hospitals are in-network for the plan. This is where we have to do some homework.
Filtering health plans
- Which doctors do you want to visit? We must verify which of your doctors are in-network for each health plan.
- Which hospitals are that you want to receive care at are in-network?
- Are your prescription medications on the carriers drug formulary and at what tier?
- Do you want a PPO, EPO, HMO, HSCP, or you don’t care?
Screening plans on these conditions will narrow down the choices to just one or two options in most cases. If you would like help filtering your health plan choices, Contact me and I can do some research for you.
The following links are to the pages with health insurance carrier information listed. I try to update the pages with the latest information and documents as they become available.
