The cost of a Covered California health plans can vary depending on several factors, including the type of plan, the level of coverage, and the region where you live. The state-based marketplace established by the Affordable Care Act (ACA) offers a range of plans with different premiums, deductibles, and co-payments. To get an accurate estimate of the cost of a Covered California plan, you can use the marketplace’s contact us for assistance. It’s important to compare different plans and consider your individual needs and budget when selecting a health insurance plan.
What You’ll Pay
Premiums: Your premium is the bill you get for having a health plan that is usually paid monthly. You or your employer, or both, pay it monthly, quarterly or yearly.
Out-of-pocket costs: a non-reimbursable expense paid by a patient. This could include any medical benefits that a plan doesn’t consider “covered services.” Your “out-of-pocket maximum” is a limit on how much you’ll have to pay for covered health services in a year. After that, your plan covers 100 percent of costs.
Deductible: The amount you owe for health care services your health insurance plan covers before your plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you have met your deductible for covered health care services. The deductible may not apply to all services.
Copay: A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Coinsurance: Your share of the costs of a covered health care service, calculated as a percentage (for example, 20 percent) of the allowed amount for the service. You pay coinsurance plus any deductible you owe. For example, if the health insurance plan’s allowed amount for an office visit is $100, and you have met your deductible for the year, your coinsurance payment of 20 percent would be $20. The health plan pays the rest of the allowed amount.
In January of 2021 and 2022, Covered California sent Form FTB 3895: California Health Insurance
Marketplace Statement to consumers enrolled in a health plan through Covered California.
Under “Covered Individuals,” Form FTB 3895 lists everyone in your household who was enrolled in a plan
and when coverage began and ended. If you changed plans during the year, you got a different Form FTB
3895 with information for that plan. Note: Covered California did not send a 3895 for minimum coverage
(catastrophic) plans.
Under “Coverage Information,” the form lists for each month of the year:
• The cost of your monthly premium.
• The cost of the premium for the second-lowest-cost Silver plan available where you live.
• How much state subsidy (called the Premium Assistance Subsidy) you received each month.
Note that in 2021, some people got more state subsidy (also called California premium subsidy or
Premium Assistance Subsidy) than they were entitled to. They may have to pay this extra money back
when they file their 2021 taxes. The government refers to paying back subsidies you used in advance as
“reconciliation.”
Take aways!
Covered California costs can vary based on several factors, including income, family size, age, location, and the specific plan chosen. Some key points to consider:
Subsidies: Many Californians qualify for financial assistance, such as premium tax credits and cost-sharing reductions, which can significantly lower monthly premiums and out-of-pocket costs.
Premiums: Premiums for Covered California plans can range widely depending on the level of coverage (Bronze, Silver, Gold, or Platinum), the insurance company, and the region. Generally, Bronze plans have lower monthly premiums but higher out-of-pocket costs, while Platinum plans have higher premiums but lower out-of-pocket costs.
Out-of-Pocket Costs: In addition to monthly premiums, individuals should consider out-of-pocket costs like deductibles, copayments, and coinsurance when comparing plan options.
Plan Comparison: Covered California offers a marketplace where individuals and families can compare different plans based on their specific needs and budget. It’s essential to carefully review plan details, including provider networks, prescription drug coverage, and other benefits.
Special Enrollment Periods: Outside of the annual Open Enrollment Period, individuals may still be eligible to enroll in a Covered California plan if they experience a qualifying life event, such as losing health coverage, getting married, or having a baby.
Cost Estimators: Covered California provides tools and resources to help individuals estimate their potential costs and determine if they qualify for financial assistance.
Medi-Cal: Some low-income individuals and families may qualify for Medi-Cal, California’s Medicaid program, which provides free or low-cost health coverage.
Penalties: Under the Affordable Care Act (ACA), most Californians are required to have health insurance coverage or pay a penalty, although there are exemptions available for certain circumstances.
By considering these factors and exploring the options available through Covered California, individuals can make informed decisions about their health insurance coverage while managing costs effectively.
Mario Arce
I have been working with Medicare clients since 2016. I serve California members in San Bernardino & Riverside county.
