Coverage Basics

Asian family; father driving with kids

Even those who are healthy today benefit from having health insurance. It's impossible to predict whether you'll get sick or have an accident, and with the average cost of a three-day hospital stay priced at $30,000, it doesn't make sense to take the gamble of going without health insurance — particularly if you can find it at an affordable price.

Through Covered California™, you can see if you are eligible for low-cost or no-cost Medi-Cal or for financial assistance to help cover the cost of a monthly premium for a Covered California health insurance plan. Covered California offers a range of plans so you can choose the one that best meets your financial situation and health needs.

If you have health insurance through your job already, your coverage will only get better as a result of the Patient Protection and Affordable Care Act. And, should you decide to leave your job tomorrow, the Affordable Care Act provides a sense of security and protection in terms of health coverage.

What does health insurance cover?

All health insurance plans now share some common characteristics. The Affordable Care Act requires that all health insurance plans offered in the individual and small-group markets must provide a comprehensive package of items and services, known as essential health benefits. These benefits fit into the following 10 categories:

  • Ambulatory patient services
  • Emergency services.
  • Hospitalization.
  • Maternity and newborn care.
  • Mental health and substance use disorder services, including behavioral health treatment.
  • Prescription drugs.
  • Rehabilitative and habilitative services and devices.
  • Laboratory services.
  • Preventive and wellness services and chronic disease management.
  • Pediatric services, including dental and vision care.

The requirement for insurance plans to offer essential health benefits is just one of many changes in health coverage as of 2014.

How do I choose a health plan?

It can be overwhelming to find the right health insurance plan for you and your family. Before you get started, it is important to understand another big change happening in health insurance. As of 2014, most health insurance newly sold to individuals and small businesses must be classified as one of the four levels of coverage: Bronze, Silver, Gold or Platinum. In addition to those four levels of coverage, a minimum coverage plan is available to those who are younger than 30 or can provide certification that they are without affordable coverage or are experiencing hardship.

This system makes it easier to compare plans. You can choose to pay a higher monthly premium for a Platinum or Gold plan so that when you need medical coverage you pay less. Or you can choose to pay a lower monthly premium for a Silver or Bronze plan, but when you need medical coverage, you pay more. It's up to you.

If you need help understanding the levels of coverage and making a choice that works for you and your family, Covered California has help available in person, online or by phone.

How much does health insurance cost?

Many people who want health insurance are concerned about the cost. Individuals seeking health coverage may get help to afford it in three different ways:

  1. Medi-Cal assistance: California has expanded its Medicaid program (called Medi-Cal in California). It covers people under age 65, including people with disabilities, with incomes of $15,856 or less for a single individual and $32,499 or less for a family of four. The coverage is free for those who qualify and is part of the provisions of the Affordable Care Act.
  2. Premium assistance: Premium assistance is available from the federal government to help reduce the cost of health coverage for individuals and families who meet certain income requirements and who do not have affordable health insurance from an employer or a government program that meets minimum coverage requirements. When you enroll in a health insurance plan through Covered California, premium assistance can be immediately applied, which reduces the amount you pay each month. To find out more about premium assistance and how the sliding scale works based on your income, try the Shop and Compare Tool (www.CoveredCA.com/shopandcompare).
  3. Cost-sharing subsidies: Cost-sharing subsidies reduce the out-of-pocket amount of health care expenses an individual or family has to pay. These expenses might include copayments for health care services or other costs you pay when you get services. To find out more about cost-sharing subsidies, visit www.CoveredCA.com/individuals-and-families.

Covered California offers assistance in numerous languages to help you enroll and to provide information about health coverage options that best meet your needs.