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Covered California


Covered California is the state’s health insurance exchange, providing health plans that comply with federal nondiscrimination and guaranteed issue laws. This means you can enroll in an insurance policy without your health status or gender getting in the way of normal prices and full access to coverage. The key perk of Covered California plans is a sliding scale premium rate, which applies to customers who earn between 138 and 400% of federal poverty. If you meet the income guidelines for tax credits, you may receive a discounted premium and even cost sharing. Financial assistance is provided by the federal government, and the state is responsible for the overall program and plan management. If you earn less than 138% of FPL, you may qualify for Medi-Cal, which now covers most low-income adults whose income is at or below this level.

California’s exchange was one of the first to be established and organized, and it runs as an independent public agency. Also called the California Health Benefit Exchange, the agency is an active purchaser, which means they select the health plans to be sold, or they negotiate costs with companies prior to offering their services. Health insurance companies must also meet the federal criteria for qualified health plans on the exchange, including essential health benefits in each policy and not restricting access to care.

Various California insurers participate on the exchange, including several smaller companies. Where you live determines which companies are offered to you with 19 different pricing regions statewide. The range of insurers may change over time, as well. Each year, the organization evaluates the health plans they provide in order to continue serving the population in the best interests of the consumer.

 

Premium and Cost Sharing Assistance

Premium rates are reduced based on how much you earn. The less you have, the more assistance you might receive. Starting at 138% of poverty, you are eligible for the largest tax credit, which will discount both your premium and cost sharing (deductibles, coinsurance and copays) as long as your income is below 250% of FPL. If you earn up to 400 percent of FPL, you may qualify for premium assistance only, though it will still help greatly compared to buying coverage without subsidies.

As the federal poverty line changes each year, eligibility will adjust accordingly from one year to the next.

Premium Assistance: 138-400% FPL

Premium and Cost Sharing Subsidies: 138-250% FPL

 

How are Tax Credits Determined?

Premium assistance is calculated as a percentage of income. Your premium cannot exceed a certain portion of what you earn if you qualify for a tax credit, and the tax credit you are awarded covers the amount that goes over that percentage so you can more easily pay for insurance.

 

Health Insurance Companies

Both large and local, the range of carriers selling coverage on the exchange are likely familiar. Plan designs are identical, but your choice of carrier will determine the number of in-network providers at your fingertips. For larger networks, opt for the national plans such as Kaiser and Anthem. To support your local medical providers and have a more intimate, personalized approach, choose the community health plan nearest you, like Valley or Contra Costa. The following health plans serve the state, leaving multiple options for each pricing region.

 

Coverage Details

Health insurance from Covered California comes in four “metal” tiers, with the least expensive, lowest amount of coverage starting at the Bronze level, and the greatest coverage and most costly plan at the Platinum level. No matter what company you choose or where you live, you will have the following options for coverage. Additionally, these plans are required to include ten groups of benefits, from preventive care to hospitalization.

Tiers of Coverage

Catastrophic: 4 office visits and preventive care covered at 100%. Emergency care at deductible. Lowest premiums for healthy young adults under 30.

Bronze: 60% of medical costs covered by your plan after deductible. Affordable premiums, higher cost sharing.

Silver: 70% of medical costs covered by your plan after deductible. Lower premiums, moderate out-of-pocket costs.

Gold: 80% of medical costs covered by your plan after deductible. Higher premiums for more coverage and less cost sharing.

Platinum: 90% of medical costs covered by your plan after deductible.The most coverage (least out-of-pocket) for a greater premium.

 

Essential Health Benefits

Here’s what’s covered by Covered California:

  • Preventive and wellness services and chronic disease management
  • Pediatric care
  • Maternity and newborn care
  • Laboratory services
  • Hospital stays
  • Emergency room visits
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Ambulatory services (walk-in)
  • Mental health and substance abuse services, including behavioral health care

If you were eligible for assistance, the table below illustrates what you might pay for covered medical services based on income level. Working on a sliding scale, the program is designed to allow you to pay what’s affordable to you. All policyholders receive preventive and wellness services at no cost with any health plan.

 

Based on the coverage tier you choose, medical costs will also vary. Copays are higher for Bronze and Silver plans than for Gold and Platinum plans. When you are searching for coverage, be sure to consider these costs in order to determine which best fits your budget.

 

Compare Covered California Plans

Below is a cost comparison tool designed to give you an idea of what to expect on the exchange in your area. These rates are estimates based on the averages released by Covered California. This tool does not provide an option to purchase plans, so we recommend calling a licensed agent at 888 803 5917 to get enrolled.

 

*The above disclaimer pertains to the creator of this comparison tool, not East Coast Health Insurance, a licensed broker of insurance products.
 

Health Plans by Region

Covered California decided to break up the state into 19 regions where different health plans would serve. Depending on your region, you may have three to six companies to choose from, which is contingent on population density. Here you can find your region (grouped by county) and discover the health plans available to you and your family on the exchange.

 

Region 1

Alpine, Del Norte, Siskiyou, Modoc, Lassen, Shasta, Trinity, Humboldt, Tehama, Plumas, Nevada, Sierra, Mendocino, Lake, Butte, Glenn, Sutter, Yuba, Colusa, Amador, Calaveras, Tuolumne

97,000 residents qualify for tax credits.

Anthem: PPO

Blue Shield: EPO

Kaiser Permanente: HMO (certain areas only)

Region 2

Napa, Sonoma, Solano, Marin
44,000 residents qualify for tax credits.

Anthem: PPO

Blue Shield: EPO

Kaiser Permanente: HMO

Health Net: PPO

Western Health Advantage: HMO

Region 3

Sacramento, Placer, El Dorado, Yolo

126,000 residents qualify for tax credits.\

Anthem: PPO, HMO

Blue Shield: PPO

Kaiser Permanente: HMO

Western Health Advantage: HMO

Region 4

San Francisco

28,000 residents qualify for tax credits.

Anthem: EPO

Blue Shield: PPO

Chinese Community Health Plan: HMO

Health Net: PPO

Kaiser Permanente: HMO

 

Region 5

Contra Costa

36,000 residents qualify for tax credits.

Anthem: PPO

Blue Shield: PPO

Contra Costa Health Plan: HMO

Health Net: PPO

Kaiser Permanente: HMO

 

Region 6

Alameda

80,000 residents qualify for tax credits.

Alameda Alliance for Health: HMO

Anthem: PPO

Blue Shield: EPO

Kaiser Permanente: HMO

 

Region 7

Santa Clara

80,000 residents qualify for tax credits.

Anthem: PPO, HMO

Blue Shield: PPO

Health Net: PPO

Kaiser Permanente: HMO

Valley Health Plan: HMO

Region 8

San Mateo

25,000 residents qualify for tax credits.

Anthem: PPO

Blue Shield: PPO

Chinese Community Health Plan: HMO (exclusive to northern San Mateo)

Health Net: PPO

Kaiser Permanente: HMO

 

Region 9

Santa Cruz, Monterey, San Benito

47,000 residents qualify for tax credits.

Anthem: PPO

Blue Shield: EPO

Health Net: PPO

Region 10

San Joaquin, Stanislaus, Merced, Mariposa, Tulare

108,000 residents qualify for tax credits.

Anthem: PPO

Blue Shield: PPO

Health Net: PPO

Kaiser Permanente: HMO (certain areas only)

 

Region 11

Fresno, Kings, Madera

65,000 residents qualify for tax credits.

Anthem: PPO, HMO

Blue Shield: PPO

Kaiser Permanente: HMO

 

Region 12

San Luis Obispo, Ventura, Santa Barbara

95,000 residents qualify for tax credits.

Anthem: PPO, HMO

Blue Shield: PPO

Kaiser Permanente: HMO (certain areas only)

 

Region 13

Mono, Inyo, Imperial

18,000 residents qualify for tax credits.

Anthem: PPO, HMO

Blue Shield: PPO

Kaiser Permanente: HMO (certain areas only)

 

Region 14

Kern

52,000 residents qualify for tax credits.

Anthem: PPO, HMO

Blue Shield: PPO

Health Net: PPO

Kaiser Permanente: HMO

 

Regions 15 and 16

Los Angeles

779,000 residents qualify for tax credits in both regions combined.

Divided by zip code, the following plans are offered in both regions serving L.A.

Anthem: EPO, HMO

Blue Shield: PPO

Health Net: PPO, HMO

Kaiser Permanente: HMO

L.A. Care Health Plan: HMO

Molina Healthcare: HMO

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