Individual and Family Health Plan Basics

Health plans can get a bit complicated so to get a better handle on your options start by considering four things:

1)   The network of doctors and hospitals used by the plan.

2)   What is the out of pocket maximum of the plan?

3)   What is the plan’s deductible and what is excluded from it?

4)   How does the plan share costs with you?  What are the co-pays or co-insurance (% of the bill) you are expected to pay?

If you have a good understanding of these questions along with the price of the plans you are in a good position to make an informed decision about your health plan. If you are on specific medications you will also want to check the formulary for the plan.

Health insurance plans (unless grandfathered) will include 10 essential health benefits in order to be considered "Qualified Health Plans". Each plan is categorized into one of four tiers: Bronze, Silver, Gold or Platinum. The tiers cover on average 60% (Bronze), 70% (Silver), 80% (Gold) or 90% (Platinum) of the cost of medical care. Each insurance company has flexibility to design its own plans within the framework of each tier and price it accordingly.

For 2016 there are 19 regions (service areas) in California and 12 insurance companies offering plans through Covered California. Not all companies are offering plans in all regions. You will have between 3 and 7 choices depending on your region. In Sacramento (Region 3) there are 5 companies offering plans.

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