Individual Insurance – What are my choices (California)?

Peter Freska, CEBS
Benefits Advisor
The LBL Group, A UBA Partner Firm

health insuranceBy all accounts, California is leading the country when it comes to On-Exchange sales (Covered California). With a total 2013-2014 marketing budget of $286,519,301, Covered California is definitely working to get the word out about their options. Also interesting to note is that reports show Covered California costs 56 times more than Facebook (more than $910 million spent on Covered California). So for all this hype and cost, Covered California has 71,188 applications completed.

The question that I still get asked almost daily is, “should I buy on the exchange?” Here is something to think about: There will be four basic levels of coverage: Platinum, Gold, Silver and Bronze. As the coverage increases, so does the monthly premium payment, but the cost when a person receives medical care is usually lower. Californians can choose to pay a higher monthly cost so that when they need medical care, they pay less. Or they can choose to pay a lower monthly cost, which means that when they need medical care, they pay more. Each person has the choice. Families can also seek insurance through Medi-Cal (California’s version of Medicaid). (Covered California Fact Sheet – Changes Coming to Health Care in 2014). In case you are wondering, this has been the case.

The answer may be as simple as answering with another question, “Do you think you might qualify for a subsidy?”

This is an important answer, because the only way to receive a premium subsidy is with the purchase of an On-Exchange plan (e.g. Covered California Insurance Marketplace).

If the answer is yes, “I may qualify for a premium subsidy,” then let’s look at the four basic tiers (Bronze, Silver, Gold, Platinum) – yes, now there are basically four metal tiers from which to choose (see key benefits below). Gone are the days of 30-40 plans from a single carrier, and gone are all the carriers in almost all the markets in the state. For example, in Southern California, Anthem Blue Cross changed their plans from Preferred Provider Organization (PPO) to Exclusive Provider Organization (EPO) On- and Off-Exchange (so check your provider network before enrolling on any plan). Their decision process is made easier by fewer plan options, but a consumer still needs to be savvy and make the choice that best meets their needs.

If the answer is no, “ I don’t qualify for a premium sudsidy,” then we can look On- and Off-Exchange. In doing so, a consumer should keep in mind that ALL the plans offered On-Exchange ARE offered Off-exchange. And yes, they are the same price! There are some more options from which the consumer may choose.

The reality is that if you qualify for a premium subsidy, then a certified insurance agent will direct you and assist you with enrollment On-Exchange. If you don’t qualify for a subsidy, then contact your trusted agent (hopefully the same as your certified agent) and they can provide you with enrollment assistance.

Bottom line: If you do not qualify for a premium subsidy, there is no reason to enroll On-Exchange. The same plans, at the same prices – with more options – are avaialble Off-Exchange. Also, the applications (at least in California) that are tried and true from the carriers work just fine! (Note: Still allow time for carrier processing.)

Deadline to submit a completed application was December 23, 2013, for a January 1, 2014, effective date. Payments must be received by Jan. 15, not just postmarked before that date. Consumers have until March 31, 2014 to get health care coverage and avoid a federal tax penalty in 2014.

To view the 2014 Standard Benefits for Individuals on the Covered California website, visit: