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Plan Selection
Covered CA lists all eligible Covered CA Health Plans on the CalHEERS website. CalHEERS features a smart sort option, allowing applicants to answer three basic questions about what is most important to them (for example, a low monthly premium) and then CalHEERS finds and displays the plans that match.
CalHEERS comparison tools let clients compare options to find the coverage that meets both their health and budget needs.
Health Plan Basics
All health plans have three elements:
- Covered services
- Premiums
- Out-of-pocket costs
Health insurance costs come from monthly premiums and the costs due when services are used.
Covered Services
Covered services (benefits) include physician visits, hospitalizations, and prescription drugs. All Covered CA Health Plans cover the 10 Minimum Essential Coverage services defined by the Affordable Care Act. While the coverage provided by all plans is the same, clients pay either lower monthly premiums or lower out-of-pocket costs depending on the metal tier the client selects.
Premiums
Several factors affect health plan premiums, including: plan design, geographic pricing regions, age, and income. Covered CA certified health plans must meet market-wide standards for coverage and accept all applicants regardless of health status.
Premium prices vary throughout the state; California has 19 geographic pricing regions. Premium rates increase with age, although never more than once a year. Health insurance companies must (1) justify premium increases and (2) spend a minimum of 80% of premium dollars on health care.
Insurance ompanies rate each family member individually. Health insurance companies charge for only the first three children under age 21 in a family; all children or dependents age 21 and older are charged a monthly premium based on their ages.
The client's income determines the amount of APTC and eligibility for CSR or state subsidies. CalHEERS completes the following calculation to determine the APTC premium assistance amount:
Cost of the 2nd lowest Silver plan for the client
minus
Client’s required premium contribution amount
equals
APTC amount*
*If this is a negative number, then the client will be ineligible for APTC even with income below 400% FPL
Out-of-Pocket Costs/Cost Sharing
Out-of-pocket costs, also known as cost sharing, are the charges a client pays for services used which are not covered by insurance companies.
Out-of-pocket costs generally include:
- Coinsurance and copayments
- Deductibles
Out-of-pocket costs generally do not include:
- Premiums
- Balance Billing amount for out-of-network doctors and hospitals
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Note: Balance Billing is when a provider bills the client for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill the client for the remaining $30. A preferred provider may not balance bill a client for covered services.
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- Costs of non-covered services
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