Health Insurance Plans Explained​: Covered California, Employer, and Medi-Cal

Whether you are new to health insurance or choosing a health plan due to a life event, this guide walks you through the main plan types you’ll find in California. Remember, having health insurance isn’t just a good idea; in California, it is the law.

The good news? All ACA-compliant plans (Covered California, most job-based plans, and Medi-Cal) cover free preventive care like checkups, vaccines, and many screenings.

How Plan Cost Works

No matter where you get coverage — through Covered California or your job — you’re usually making the same basic trade-off:

• Lower monthly payment, higher out-of-pocket costs, or

• Higher monthly payment, lower out-of-pocket costs

In other words, you can save money each month but pay more when you actually use care or pay more each month so the plan covers more of the bill when you go to the doctor, hospital, or pharmacy.

For Medi-Cal, this trade-off is different. If you qualify, Medi-Cal usually has no monthly premium and very low copays, so you’re not picking a deductible. Your choice is more about which Medi-Cal plan and doctors you use than how much you pay each month.

Covered California Health Plans

Covered California is a free state-run service helping residents get quality brand-name health insurance — but we’re much more than that. Through Covered California, you can shop for a plan that works for you, your family, or your small business. If you qualify, you’ll also get financial help toward your monthly premium (four out of five get financial assistance).

Plan Coverage Tiers

Plans through Covered California have four coverage levels grouped into metal tiers. The benefits are the same for each tier, but they differ in how you and your insurance company split the cost of that care. These are the four coverage levels:

• Bronze plans cover 60 percent of health care costs, while you pay 40 percent.

• Silver plans cover 70 percent, while you pay 30 percent.

• Gold plans cover 80 percent, while you pay 20 percent.

• Platinum plans cover 90 percent, while you pay 10 percent.

Within the Silver plan, there are four cost-sharing reductions (CSRs). If your income is in a certain range and you pick a Silver plan, you may qualify for an extra financial help:

• Silver 70

• Silver 73

• Silver 87

• Silver 94

Minimum Coverage Plan

If you’re under 30, you might be able to get a minimum coverage plan, also called a catastrophic plan. These are really meant for “worst-case scenario” coverage — the premium is usually lower, but the deductible is very high. If you’re 30 or older, you’d need a special exemption to sign up for one.

Before you go that route, it’s a good idea to compare it to a Bronze plan, which is often a better overall deal.

Plan Network Types

Plans through Covered California are the most common health plan types. The difference between plan types is flexibility on what doctors and specialists are covered. The provider network types are:

• HMO (health maintenance organizations), where you must stay within your provider network and referrals are often required to see a specialist, except in case of emergency. HMOs are often the most affordable option.

• EPO (exclusive provider organizations), where you must stay within your provider network but don’t need a referral for a specialist. EPOs are a combo of HMO and PPO features, but less expensive than PPOs.

• PPO (preferred provider organizations), where you have the most flexibility and can see in- and out-of-network providers. PPOs are the most expensive health plans.

Benefits Covered by All Plans

Covered California works with many different health insurance companies whose prices and availability vary by location. No matter where you live, all plans available through Covered California include emergency care, preventive and wellness services, hospitalization, and more. Here are the benefits covered by all plans.

Make sure the plans you are considering cover the care you need, including prescriptions. If you take a specific medication, take a look at each plan’s prescription drug coverage (often called a “formulary”) to ensure the medication is covered and how much your out-of-pocket cost would be.

In addition, consider the following when shopping for health plans: Who needs coverage? How often do you visit the doctor? What services do you need covered?

Finding Financial Help

Covered California is the place to get financial help for plans from top health insurers. Ninety percent of people who enroll through Covered California qualify. Learn about how this works through both premium tax credits to lower the cost of your monthly premium and cost-sharing reductions that save you money when you get care.

You can get a quick estimate to find out how much financial help you might get here.

Covered California Dental and Vision Plans

When you enroll in a health plan through Covered California, it’s easy to add dental insurance. Keep in mind, you do need to sign up for a health plan to add a dental plan. Vision insurance for adults is not available through Covered California, but you’ll find links to trusted providers on our website, where you can explore vision plans and sign up for coverage.

All health plans through Covered California include dental and vision coverage for children under the age of 19.

When choosing dental insurance through Covered California, you have two types of plans:

• DHMO Dental Plans have no deductible or annual benefit limit. No matter how much care you need throughout the year, your DHMO plan continues to help you pay for it. There’s no waiting period for major services, but you have to see a dentist within your provider network (except for emergencies).

• DPPO Dental Plans charge a deductible, and there’s a limit to how much the plan pays for treatments each year. Preventive care is also free with DPPO plans. Instead of a flat fee, DDPO plans cover a percentage of the cost for different treatments. There’s a six-month waiting period for major services for adults. You can see both in-network and out-of-network dentists, however, costs can vary.

Check here to get a side-by-side look at how these types of plans compare.

Employer-Sponsored Health Plans

For a lot of people, the easiest place to find health insurance is at work. About 7 out of 10 workers have access to health insurance through their job, so check with HR or your manager to see what’s offered. Even some part-time jobs include health coverage.

Employer-based plans don’t usually use the “Bronze / Silver / Gold / Platinum” labels like Covered California, but the setup is similar. You’ll still see things like HMO, PPO, or EPO, and sometimes a high-deductible plan that can be paired with a HSA.

Also important: Even if your employer does offer insurance, you might still qualify for Covered California if that job-based coverage is too expensive. If the cheapest plan they offer just for you costs more than a certain percentage of your household income, you may be able to get a plan through Covered California with financial help.

You can plug your numbers into the Covered California Affordability Tool to see if that applies to you.

Medi-Cal Health Plans

Medi-Cal is California’s Medicaid program that offers free or low-cost health coverage for people with low incomes. You can apply for Medi-Cal online, by phone, or in person through Covered California — the same application will let you know which program you qualify for. How easy is that? You can also apply at your county social services office or by mail.

Most people get Medi-Cal through a managed care health plan, kind of like an HMO. What is available to you depends on your county, age, and other factors.

Big picture, Medi-Cal is delivered two ways:

• Straight Medi-Cal, where the state pays doctors directly. This is less common and usually for special situations.

• Medi-Cal Managed Care, where you enroll in a health plan with a network of doctors, hospitals, and clinics that coordinates your care. Over 80% of enrollees are in this type of plan.

Medi-Cal Managed Care Models

California sorts Medi-Cal plans into different models by county. That’s why some counties have one Medi-Cal plan, some places give you a choice between a local public plan and a big-name company, and others have a few commercial plans to choose from.

Bottom line: Someone in Los Angeles will see different options than someone in Stockton or San Diego. To see what’s available where you live, you can hop onto the Department of Health Care Services (DHCS) Medi-Cal Health Plan Directory and plug in your county.

Special Medi-Cal Plan Types

Depending on your situation, you might have some options that sit on top, or alongside of, your Medi-Cal managed care plan.

• Medi-Medi plans are for people who have both Medicare and Medi-Cal. They usually combine a Medicare Advantage plan and your Medi-Cal plan under the same company, so you get one card and one network to figure out.

• The Program for All-Inclusive Care for the Elderly (PACE) is for some older adults who need more help with day-to-day care. PACE bundles Medi-Cal, long-term care, and social services into one program, allowing members to stay in their communities.

• Medi-Cal Dental (often called Denti-Cal) is Medi-Cal’s dental coverage. It runs as a separate program with its own provider network.

When You Can Sign Up for a Plan

Open enrollment for Covered California runs annually from November 1 through January 31. You can buy health insurance or change your existing health plan for the upcoming year at any point during this time. Sign up online, by phone, or in person. Major life events qualify you for a special enrollment period through Covered California outside of open enrollment. There’s no deadline for enrolling in Medi-Cal.

Get Covered

When you need coverage, Covered California can help you find the health plan and financial help you need. At any time, you can get a quick quote to find out how much financial help you might get to pay for your health plan. Free expert help is available year-round over the phone, in person, and online.

Ready to get covered? You can start here to find a health plan that meets your needs.