Coverage California ACA Buyer Guide: Covered California

The Regular Open Enrollment (2015) is Complete, but the 2016 Open Enrollment begins November 1st

By Marc Derendinger  

The purpose of this Coverage California Buyer Guide is to help individuals, families, and early retirees take full advantage of the Affordable Care Act (ACA) Open Enrollment and Special Enrollment seasons, and avoid mistakes that could cost you money and opportunity under Covered California (Obamacare) and the private market.  This is a good reference article, so retain it until you need it.

Remember, Open Enrollment begins November 1st, but you may qualify to enroll sooner under a Qualifying Event Special Enrollment provision of the Affordable Care Act (ACA).  We published an introductory article about Special Enrollments here.

Buyer beware, because changes are coming to certain PPO networks.  If you did not use a Certified Agent last year, now is a good time to find one…they are a free service of Covered California and the good ones can help guide you through the network provider “game of hide & seek” that is being played by California health insurance companies, at the expense of California residents.

Health plans take on a new design structure, with new metallic” plans. (If you already know about metal plans and want to skip ahead to more advanced topics in this series, click here)

Unless you are insulated from all these changes through your participation in a Grandfathered plan, by 2014-2016 you will start to see insurance talk about “metals,” including Kaiser members (for more information on Obamacare vs. Kaiser, Click Here.)   For example, Bronze plans cover an average of 60% of costs, meaning that, on average, you will be responsible for paying 40% of your health care costs.  Also, most services covered by the Bronze plan are subject to a deductible or amount you must pay out-of-pocket before the plan will cover costs.

Download a PDF of the Metallic plans here:  CoveredCA Health Plan Benefits Summary

While the Bronze plan has the cheapest monthly premium, Silver Plans provide a lower risk of out-of-pocket costs, making it a better value for most people. Silver 70 plans cover an average of 70% of costs, meaning that, on average, you will be responsible for 30% of your healthcare costs.  Most common covered services under the Enhanced Silver Plan do not have a deductible.

The higher the metal value, the higher the value of benefits covered under the plan.  Hence, Gold plans expect to cover an average of 80% of the cost of medical services and Platinum, an average of 90%.  Higher benefits also lead to higher premiums, so talk to a certified professional to analyze all your options.  Under California law, only Certified Insurance Agents can compare your options under Medi-Cal vs. Covered California public exchanges vs. private market plans.  There is no added cost when you use these experts.

Insurers Will Battle Within Metal Tiers

If you are looking to benefit from lower prices in a new competitive market, I suggest starting with the Silver Tier, where five insurance companies (in Santa Clara County) compete for your business (see our Obamacare Rate Guide for examples).  Since they offer similar plans within the metal tier, companies are forced to compete on price and provider network.

For additional employer requirements under the Affordable Care Act legislation click here.  For rate comparisons of new group health plans, click here.  For non-group e.g. individual family plans click this link.

Got questions? Frustrated with the Affordable Care Act?  Life’s too short to waste time with all this:  Request free consumer assistance from Certified Insurance Agents, below:

Editor’s Note:  Marc Derendinger has 30-years experience in the California health insurance marketplace and serves on the agent advisory group for the State of California Department of Healthcare Services California Partnership for Long-term Care.  His insurance brokerage is located in San Jose and advises many well-known organizations e.g. San Jose Police Officers’ Association, City of Campbell, City of Santa Clara, plus individuals and family businesses throughout Northern California.California License No. 0563986