California's Health Insurance Marketplace
Last updated October 2018
It can be overwhelming to find the right health plan for you and your family. Before you get started, it is important to understand your options.
Our staff at OnlyHealthInsurance is fully informed about health care reform. As insurance brokers we went through extensive training in preparation for the health care reform launch. We gained a great deal of experience from the first open enrollment period. Couple this with over 25 years of working in the individual and family health insurance market in California, and we have become a leading expert and producer in this market.
The information below is a summary of some of the important aspects of the California insurance market. I hope you find it useful in your research.
Before purchasing coverage, please click here to check out our new explanatory video.
Health care reform brought with it several changes to the healthcare system. As of January 1, 2014, denying coverage or charging higher premiums to anyone with a pre-existing condition is prohibited. Other significant reforms have been made such as expanded preventive care services; dependents are now able to stay on a parent's insurance plan until age 26, and removal of annual and lifetime coverage maximums. Carriers are also required to spend at least 80% of premium dollars directly on health care. Along with these changes and other mandates, individuals without a qualifying alternative can now face fines if they don't purchase health insurance. Two Ways to Enroll
California has two marketplaces or exchanges in which to obtain ACA-compliant health insurance, the Public Exchange or the Private Exchange.Public Exchange
Covered California is the public marketplace and is California's version of ObamaCare. This is the market in which premium subsidies and cost sharing reduction assistance is available for those who qualify. Eligibility for assistance is based on household income and family size.
This market is managed through the CoveredCA website, www.coveredca.com, where one can register, disclose required personal and financial information, compare plans, and enroll in coverage. Enrollment support is available from CoveredCA representatives, insurance brokers, and registered navigators. To find out if you qualify for assistance, click here to use CoveredCA's Shop and Compare tool. If you qualify for financial assistance, and wish to take advantage of it, you can enroll for coverage in the Public Exchange.Private Exchange
The other marketplace is called the "private" market or "off exchange" market, where coverage can be obtained directly from an insurance carrier. There is no financial assistance available in this market. Because of this, there is no financial information required, which makes for a simpler enrollment process. Also, some carriers have chosen to only offer plans in the private exchange, resulting in more carrier choices and plan options. For those who don't qualify for financial assistance, or who prefer not to enroll through CoveredCA, the Private Exchange is the marketplace to enroll through.
can be of service to consumers is by offering plans through the Private Exchange.
If you are considering individual or family health insurance, have decided to enroll in a private exchange plan, or are not sure what type of plan you're eligible for, we hope you will contact us for assistance. After understanding your personal circumstances and health insurance needs, we can make an assessment and recommendation for the most appropriate solution. If it is determined that applying though CoveredCA is your best option, we can provide you with a referral to a knowledgeable broker who works in the Public Exchange market.
If you have individual insurance that started on or before the Affordable Care Act was passed (March 23, 2010) and has stayed the same since, your plan is said to be "Grandfathered" and you may keep it indefinitely if you so choose. Grandfathered plans do not have to comply with all of the mandates outlined in the new healthcare reform law (ACA). Note: Consider your options carefully before terminating or replacing a grandfathered plan. They offer some advantages over the reform plans (non-grandfathered) and once terminated you cannot get it back. Eligibility for Insurance
Legal residents of California may be eligible to buy health coverage through CoveredCA and receive financial assistance. Those unlawfully present in CA may still qualify for some assistance. Legal residents of California are also eligible to buy health coverage through the private market exchange.Open Enrollment
Each year there is an annual open enrollment period (AEP) when consumers can research, change, and enroll in a health plan for the following plan year. For the 2019 plan year, the open enrollment period runs from October 15, 2018 through January 15, 2019. To be eligible for a January 1, 2019 effective date, you must enroll no later than December 15, 2018.Special Enrollment
If you have a life-changing event, such as the loss of a job, a move, a marriage or divorce, or the birth of a child, then you may qualify for "special enrollment" in either Covered California or the private marketplace. The special enrollment period runs 60 days before and 60 after the date of the life event. An application with supporting documentation of the life event must be submitted during this time period for successful enrollment. Insurance carriers may have additional rules and documentation requirements for enrollment so it's important to check with your broker.Essential Benefits
All individual health insurance plans offered through the health insurance marketplace cover a comprehensive set of benefits known as "essential health benefits." All newly sold health insurance plans — whether sold through CoveredCA or in the private marketplace — will cover these services.
They include the following 10 categories:
- ambulatory patient services
- 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
- laboratory services
- preventive and wellness services and chronic disease management
- pediatric services, including oral and vision care
In addition to the essential health benefits, all health plans are offered with standard benefit designs so you can make apples-to-apples comparisons between plans.Standard Benefit Designs
Plans must fall into four categories of coverage based on the overall percentage of cost-sharing of the plan: platinum level at 90%, gold level at 80%, silver level at 70%, and bronze level at 60%, as well as a catastrophic plan for individuals under 30 years old. Each category of plan must cover the essential benefits mentioned above, but with co-insurance, deductibles, and copays to correspond to the level of coverage. The private marketplace offers these same standard designs as well as other plan options that meet the benefit level cost sharing requirements. Click here to see the 2019 Standard Benefit Designs and Medical Cost Shares.