Individual and Small Group Plans

As of January 1, 2014, all new individual and small group plans are classified into one of four metal categories:  platinum, gold, silver or bronze.

–          Platinum plans cover 90% of healthcare costs

–          Gold plans cover 80% of healthcare costs

–          Silver plans cover 70% of healthcare costs

–          Bronze plans cover 60% of healthcare costs

Platinum plans have the highest monthly premiums but the lowest out-of-pocket costs such as deductibles, co-pays and coinsurance.  Bronze plans have the lowest monthly premiums but the highest out-of-pocket costs.   Catastrophic plans are available for individuals under 30 years old, and those over 30 who can prove financial hardship.

Rates are based on the metal plan chosen along with the applicant’s age, zip code, and number of covered dependents.  There is no medical underwriting and no Risk Adjustment Factors.  Individuals may not be denied coverage or charged an increased rate due to medical history.

All individual and small group health plans must provide a comprehensive set of benefits known as Essential Health Benefits which include:

  • 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 oral and vision care

Individuals and small groups may purchase coverage directly from a carrier  or through our state exchange.  Plans sold in the exchange must also be sold outside the exchange with the exact same benefits, rates and networks.  There are additional carriers and plans offered outside the exchange.  These plans  still use the tiered metal system but may have narrower doctor networks and lower premiums.

Individuals and families with “grandfathered” status may be able to keep their current plan.  (You have “grandfathered” status if the plan you have now is the same plan you had on March 23, 2010 when the Affordable Care Act was signed.)  Once you lose grandfathered status you can’t regain it so review your options carefully before voluntarily giving up your grandfathered status.

Individuals and families without access to employer-sponsored health insurance may enroll in an individual plan during the annual open enrollment period.  Individuals are only allowed to enroll outside of open enrollment if they have a “qualifying event” such as involuntary loss of coverage, marriage, birth or adoption of a child, etc.   Individuals who experience a qualifying event have 60 calendar days from the date of the event to enroll in a plan.  The next open enrollment period will be from November 1, 2015 through January 31, 2016.  The open enrollment period applies to plans purchased on and off the exchange.

If you have questions about your existing plan, or would like to compare your options, please call us today at (916)467-4647.