Finding the right plan for you or your family can be a frustrating. The good news is we are here to help! Let us walk you through the decision process with straightforward, easy-to-understand answers.
Find the health plan that best suits your needs and budget.
Understanding Your Options
Today, all of the plans in the individual/family market must comply with the Affordable Care Act (ACA) Law. What this means is that plans are now offered in four tiered “metal levels”: Bronze, Silver, Gold and Platinum. All of these plans cover the same “10 Essential Health Benefits” and follow specific actuarial values. The difference between the four tiers lies in how much of the bill you must pay and how much is paid for by the insurance company. Within each of these four tiers you also have the option of selecting between EPO, PPO, HMO and HSA plans. These terms are explained below.
What are the “10 Essential Health Benefits” that all plans must cover?
All plans must offer coverage for:
• Ambulatory patient services
• Emergency services
• Laboratory services
• Maternity and newborn care
• Mental health & substance abuse services
• Rehabilitative services and devices
• Pediatric services, including pediatric dental care
• Prescription drugs
• Preventive and wellness services
• Chronic disease treatment
What are the differences between the 4 “Metal Levels”?
All plans must fit into one of 4 “metal levels”: Bronze, Silver, Gold or Platinum. While all plans cover the same benefits, each level differs in the out of pocket cost for you. In addition, each plan must follow specific Actuarial Values for each of the plans. The actuarial value is the percentage of total allowed costs paid by the plan, as opposed to the percentage paid by the participant.
Bronze: Your health plan pays about 60%. You pay about 40%.
Silver: Your health plan pays about 70%. You pay about 30%.
Gold: Your health plan pays about 80%. You pay about 20%.
Platinum: Your health plan pays about 90%. You pay about 10%.
Note: Most plans have restrictions in place to ensure that you receive your care from doctors and facilities that are in a specific networks of providers. It’s important that you research to see if your preferred doctors/providers/facilities are within the carrier network associated with the plan that you select. Plus, keep in mind that these networks can and do change without notice.
How do you sign up for Covered California?
Covered California is the program through which you may qualify to receive an “Advance Tax Subsidy” from the State of California to help cover the cost of your health insurance premium.
To take advantage of this, here’s what you need to do:
• Go the Covered California website and select the “Shop and Compare” tab.
• Select the coverage year for which you want to see rates.
• Enter your total household income and zip code.
• Enter the age of each family member who will or may be enrolling in the program.
• Select “See My Options.” The site will now display available plans. For each plan you will see your total monthly payment, the amount of monthly premium assistance that may be available to you and the total monthly premiums (i.e. your total monthly payment plus the amount of the monthly premium assistance).
• Click on “View Details” to see a cost break down, list of plan benefits and information about the insurance company.
If you need assistance with this process, please feel free to contact our office.