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Health Under 65

Buying your own health coverage

Under 65 and buying for yourself or your family? Here is how individual and family plans work in California, including Covered California.

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Three questions

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Step 1: which coverage are you thinking about?

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Covered California

How individual and family plans work

In California, the state marketplace for individual and family health plans is Covered California. Open Enrollment runs from November 1 to January 31.

Outside Open Enrollment, a major life change, like losing other coverage or moving, can let you enroll. Most of those special enrollment periods last 60 days from the change.

Depending on your household income, you may qualify for financial help that lowers your monthly premium. Covered California and Medi-Cal use the same application.

Before you pick a plan, check that your doctors are in its network and price your actual prescriptions. Two plans with the same premium can cost very different amounts across a year.

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How costs work

What you pay, and when, across a plan year

What you pay, and when, across a plan year An axis of annual covered spending crossed by two markers. Before the deductible is met you pay most covered bills at the negotiated rate, and the plan pays for preventive care and, in many plans, part of some visits after a set copay. Between the deductible and the out-of-pocket maximum you pay a copay or coinsurance share on each bill and the plan pays the rest. Once the out-of-pocket maximum is met the plan pays 100 percent of covered care through year end and you pay nothing more for in-network care. The premium runs unbroken underneath all three regions: it is due every month whether or not you use care, and none of it counts toward either marker. Financial help with premiums lowers the premium line only. Cost-sharing reductions move both markers left and attach to Silver plans only. What you pay, and when, across a plan year Structure: healthcare.gov (CMS) · not to scale; every plan sets its own amounts Annual covered spending Deductible met Out-of-pocket maximum met Cost-sharing reductions move both markers left · Silver plans only Before the deductible Between the markers After the maximum You pay Most covered bills, at the negotiated rate Your coinsurance or copay on each bill Nothing more this plan year, in network Plan pays Preventive care, and some visits with a copay The rest of each bill, after your share 100% of covered care, through year end Premium Due every month, used or not, and none of it counts toward either marker. Financial help with premiums lowers this line, and only this line. Both markers reset at the start of each plan year. Out-of-network care may not count toward either. Some plans charge a set copay for certain visits or drugs before the deductible. Check the plan summary. What you pay, and when, across a plan year A vertical axis of annual covered spending, running down the page and marked at two thresholds in order. Before the deductible is met you pay most covered bills at the negotiated rate, and the plan pays for preventive care and, in many plans, part of some visits after a set copay. Between the deductible and the out-of-pocket maximum you pay a copay or coinsurance share on each bill and the plan pays the rest. Once the out-of-pocket maximum is met the plan pays 100 percent of covered care through year end and you pay nothing more for in-network care. The premium runs unbroken alongside all three regions, as a rail down the right-hand side: it is due every month whether or not you use care, and none of it counts toward either marker. Financial help with premiums lowers the premium line only. Cost-sharing reductions move both markers up the axis and attach to Silver plans only. What you pay, and when, across a plan year Structure: healthcare.gov (CMS) · not to scale; every plan sets its own amounts Annual covered spending Before the deductible You pay Most covered bills, at the negotiated rate Plan pays Preventive care, and some visits with a copay Between the markers You pay Your coinsurance or copay on each bill Plan pays The rest of each bill, after your share After the maximum You pay Nothing more this plan year, in network Plan pays 100% of covered care, through year end Cost-sharing reductions move both markers up the axis · Silver plans only Deductible met Out-of-pocket maximum met Premium Due every month, used or not, and none of it counts toward either marker. Financial help with premiums lowers this line, and only this line. Both markers reset at the start of each plan year. Out-of-network care may not count toward either. Some plans charge a set copay for certain visits or drugs before the deductible. Check the plan summary.
Structure: healthcare.gov (CMS). Not to scale; every plan sets its own amounts.

Coverage Pedro can help with

Health under 65MedicareTurning 65Medicare AdvantagePart DMedicare SupplementDental & VisionLife insuranceExtra coverageMedicare guides

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Questions

Questions people ask

Open Enrollment runs from November 1 to January 31. Outside that window, a major life change, like losing other coverage or moving, can open a special enrollment period, usually for 60 days.

Many people can. Financial help depends on your household income and size, and your application shows what you qualify for. Covered California and Medi-Cal use the same application.

Group health coverage offered through an employer works differently from an individual plan. Limited-benefit policies pay set amounts for specified services and are not replacements for comprehensive health insurance. California prohibits the sale or renewal of short-term limited-duration health policies.

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