Obamacare in California
If you've arrived at this page, you may be wondering how the Affordable Care Act affects California residents. The 2010 Affordable Care Act, also known as Obamacare, is health-care reform legislation aimed at making health insurance more affordable and accessible for Americans. The law also establishes health insurance Marketplaces, or "exchanges," which are government-run websites where you can go to purchase health coverage for yourself or your family if you don't already have it.
There are two kinds of Marketplaces available, and the type you have access to will depend on the state you live in. There's the federal health insurance Marketplace (also known as Healthcare.gov) in some states, and there are state-run Marketplaces in other states. California has its own state health exchange set up, also known as Covered California.
If you already have health insurance (for example, through an employer), it's likely that you don't need to make changes to your coverage. However, if you don't already have health coverage and aren’t eligible for an exemption, you could face a tax penalty under Obamacare unless you enroll in a health plan.
Covered California is the state health insurance exchange, but it isn't your only option if you're purchasing a health plan on the individual and family Marketplace. You can also find health coverage directly through insurance companies -- or through a licensed insurance broker like eHealth.
To learn more about how Obamacare works in California and your health coverage options, read on.
Am I eligible for Obamacare health coverage?
In California, like the rest of the country, the Affordable Care Act requires most U.S. citizens, U.S. nationals, and permanent residents to have health coverage that meets minimum coverage requirements. Unless you qualify for an exemption, you could pay a tax penalty if you go without health coverage for two months in a row or longer.
If you aren't in the United States lawfully, you are exempt from the requirement to have health coverage. You won't be eligible to enroll in a health plan through the California health insurance exchange, although you may be able to enroll in private health insurance outside of Covered California.
If you aren't legally present in the country, you can still apply for health coverage through Covered California through a lawfully present family member (for example, through a dependent child). For more information on health coverage eligibility in California, visit CoveredCA.com.
Types of health plans on the California health insurance exchange
Like in the rest of the United States, the health plans available on Covered California fall into four metal levels. The metal levels reflect the costs you can expect to pay for health plans in each category; they don't have to do with the quality of care.
Health plans sold on the California health exchange fit into the following four metal levels:
- Bronze level: On average, your plan pays 60% of covered health-care costs; you pay the remaining 40%.
- Silver level: On average, your plan pays 70% of covered health-care costs; you pay the remaining 30%.
- Gold level: On average, your plan pays 80% of covered health-care costs; you pay the remaining 20%.
- Platinum level: On average, your plan pays 90% of covered health-care costs; you pay the remaining 10%.
The California health exchange also offers an Enhanced Silver plan for certain individuals with limited income who qualify for lower out-of-pocket costs. With an Enhanced Silver plan, eligible individuals who purchase a Silver plan will have the lower cost-sharing benefits of a Gold or Platinum plan -- but for the cost of a Silver level plan. There are three types of Enhanced Silver plans available, and each type has a different level of cost sharing:
- Plan pays 94%: On average, your health plan pays 94% of health-care costs; you pay the remaining 6%.
- Plan pays 87%: On average, your health plan pays 87% of health-care costs; you pay the remaining 13%.
- Plan pays 73%: On average, your health plan pays 73% of health-care costs; you pay the remaining 27%.
Minimum coverage plans may be another coverage option if either of the following is true for you:
- You're under 30 years old.
- You cannot afford health coverage or otherwise qualify for a hardship exemption.
Also known as "catastrophic" coverage in some states, minimum coverage plans are another class of health insurance and cover the same minimum essential benefits as other Marketplace plans. These plans typically have lower premiums than other health plans, but you'll need to meet a high deductible before the plan begins to pay for most medical costs. Minimum coverage plans are designed to protect you in a "worst-care scenario."
In California, minimum coverage plans do cover some benefits before you reach the deductible. You generally won't have to pay copayments or coinsurance for the following benefits (even if you haven't met your deductible yet):
- Three doctor visits
- Urgent care visits
- Outpatient mental health or substance abuse care
- Free preventive benefits
With the exception of the above benefits, you'll pay 100% for all other health-care services until you meet the plan deductible. In California, those enrolled in a minimum coverage plan pay a negotiated in-network cost for health-care services. After your out-of-pocket spending has reached the deductible, the plan pays for 100% of covered health-care benefits.
What benefits do Obamacare health plans cover?
In California, as in the rest of the United States, all health plans sold on the individual and family Marketplace must meet minimum coverage requirements, or "essential health benefits." These required benefits include:
- Ambulatory services
- Emergency or urgent care
- Hospitalization services
- Maternity and newborn care
- Mental health and substance abuse services, including counseling
- Prescription medications
- Rehabilitative services and equipment
- Laboratory services
- Preventive and wellness care, including chronic-condition management
- Pediatric services (which must include dental and vision care for children)
All health plans sold on the California health insurance exchange include pediatric dental care as a covered benefit. Dental coverage for children under 19 is an essential health benefit, and pediatric dental services are "embedded" into the health plan.
Adult dental services are not a minimum health coverage requirement, and health plans are not required to cover dental care. Dental coverage is optional, so there isn't a penalty if you don't get dental insurance. If you do want adult dental coverage, you'll need to purchase this coverage through a stand-alone dental plan and pay a monthly premium for it.
Starting with the 2016 plan year, you'll have the option to enroll in a stand-alone dental plan on Covered California. If you have children, they're automatically covered for dental services by any health plan sold through the California health exchange. However, if you like, you can purchase a separate family dental plan that may offer additional pediatric dental benefits. Or, alternatively, you can find a wide selection of dental plans through a licensed insurance broker, such as eHealth.
Getting help with health-care costs
California residents with limited income may qualify for help with health-care costs. Depending on your income level and eligibility, you may qualify for lower premiums, also known as premium tax credits or other subsidies. In some cases, in addition to lower premiums, you may also be eligible for help with cost-sharing expenses like copayments, coinsurance, deductibles, and out-of-pocket maximums.
If you think you may qualify for lower premiums or out-of-pocket costs, you can apply for a subsidy at the same time that you enroll in a health plan. You can enroll in a plan through Covered California to get these savings. Important note: Those who qualify for lower cost sharing must enroll in an Enhanced Silver plan; these plans automatically include lower copayments, coinsurance, deductibles, and out-of-pocket maximum limits.
To be eligible for financial assistance, you must:
- Be a U.S. citizen, U.S. national, or legally present in the United States.
- Purchase a health plan through Covered California.
- Not be receiving Medi-Cal, military health benefits, or premium-free Medicare Part A.
- Not have access to affordable coverage through your work.
- Have a household income between 100% and 400% of the Federal Poverty Level. For a family of four in 2015, this would be a household income between $23, 850 and $95,400.
Some individuals with limited income may qualify for Medi-Cal, California's state Medicaid program. If you're eligible for Medicaid, you'll get your health coverage through the program. If you get Medicaid, you've met the requirement to have health coverage and won't face a tax penalty. You won't need to enroll in a separate health plan. To find out if you're eligible for Medicaid and to apply, contact the California Medicaid department.
How can I enroll in a health plan in California?
If you're a California resident, you'll have a couple of options when it comes to finding health coverage in the state, including:
- A licensed insurance broker, such as eHealth
- Directly through an insurance company
- Covered California, the state health insurance exchange
You can apply through Covered California by:
- Submitting an online application on CoveredCA.com.
- Calling 1-800-300-1506 (TTY: 1-888-4500), Monday to Friday, from 8AM to 6PM PT; Saturdays from 8AM to 5PM.
- Applying in person with a certified enroller, insurance agent, or county services agency. Visit CoveredCA.com to get in-person assistance.
- Mailing a paper application.
When you apply for health insurance, you may be asked to provide information such as the following on the application:
- Information on household members who need coverage
- Mailing address
- Social Security information
- Documents that verify U.S. citizenship or lawful immigration status
- Work and household income
- Federal tax information
Remember, the California state insurance exchange is just one option for enrolling in a health plan. You can also find health coverage directly through an insurance company or through an insurance broker like eHealth. Plan availability and coverage details may vary, depending on where you purchase your health coverage. For example, eHealth’s website may have some health plans for your area that are not available on Covered California.
When can I enroll in a health plan?
Like the rest of the country, California residents may enroll in a health plan for the upcoming plan year during the Open Enrollment Period, which occurs this year from November 1, 2015 to January 31, 2016.
If you successfully apply between November 1 and December 15, your coverage can start as early as January 1 of the following year. For example, if you successfully apply on November 15, 2015 for a 2016 health plan, your 2016 coverage will typically start January 1, 2016. The exact coverage start dates will depend on the policies and procedures of the health insurance company you choose and other factors such as whether your application had any errors.
After Open Enrollment has ended, you can only enroll in a health plan if you qualify for a Special Enrollment Period. You get a Special Enrollment Period when you experience a qualifying life event, or a situation that makes you eligible to make changes to your health coverage. If you're eligible, you'll have 60 days from the date that the qualifying life event occurred to enroll in a new health plan or make changes to your current coverage.
Some examples of qualifying life events may include, but aren't limited to:
- Losing your health insurance (for example, if you have employer-based coverage and lost your job).
- Getting married or divorced.
- Entering into a domestic partnership.
- Having a baby or adopting a child.
- Becoming a U.S. citizen, U.S. national, or lawfully present individual (if you weren't previously).
- Moving to a new area with different coverage options.
If you're applying for financial assistance, such as Medi-Cal, you can apply at any time of the year.
Frequently asked questions about Obamacare in CaliforniaIf I have pre-existing conditions, how will this affect my health coverage? What if I'm a smoker?
In California, you cannot be denied health coverage or charged higher premiums because of pre-existing conditions, including tobacco use. While most other states allow health insurance companies to charge higher premiums for smokers and tobacco users, California does not. If you are a California resident and a tobacco user (including cigarettes, cigars, or chewing tobacco), this will not affect your health insurance premiums.Am I eligible for a subsidy?
Eligibility for subsidies, which help with certain health-care costs, is dependent on household size and income. You may be eligible for lower premiums and, in some cases, out-of-pocket savings. In California, as in the rest of the country, your modified adjusted gross income and household size is used to determine your eligibility. You can use eHealth's Subsidy Calculator tool to find out if you're eligible for help with health-care costs.Which health plan is right for me?
There isn't a "one-size-fits-all" when it comes to health coverage, and the health plan that may work for your needs will depend on your health status, budget, preferences, and unique situation. There are online resources available for people with special circumstances, including students, veterans, Medicare beneficiaries, and people with Medicaid. If you fall into one of these groups, visit eHealth's Obamacare Resource Center for resources that may help guide your health-care decisions.
If you need help finding coverage options that may work for you, an eHealth licensed insurance agent can help. Contact eHealth today for personalized assistance with your health-care options.
This article is for general informational purposes only, and may not always apply to your specific situation or insurance policy. You should always carefully read the plan information and benefits for any insurance plan you are considering. A licensed insurance agent can help you understand the specifics of a policy.