Individual & Family Solutions

The Health Care Exchange ...2020 Open Enrollment November 1, 2019 - December 15, 2019 (California residents may see an extension of time posted later in 4th quarter).  Coveredca members start to make their updates Oct 15, 2019. New FPL income levels for California residents (140% - 600%) may see adjustments in subsidies. Look for mobile app and new shop & compare tool.  California to re-establish the penalty rules for not having health insurance in 2020.

Federal 2020 Open Enrollment other states November 1, 2019 - December 15, 2019

Open Enrollment for new ACA (Affordable Care Act) plans continues in California and with other state Health Care Exchanges.  The Affordable Care Act brought about changes to the health insurance plans in both the individual and group markets. We will see some plan changes for 2018 in all markets in addition to rising premiums. Anthem in California with discontinue their individual health plans except for 3 Northern California counties.  This Anthem announchement does not effect those with grandfathered plans, group health insurance or Medicare Advantage plans. Everyone who signs up during open enrollment will be given a January 1st effective date.  Please contact our office before November 1st to discuss your options for change and set an appointment. Those enrolled via CoveredCA are encouraged to make their plan changes before December 15th or will be passively enrolled in a low cost plan.  Also look for our next newsletter.  

Each year you should review the Essential Benefits of your plan, pediatric dental and vision benefits if you have children under 19 on your plan,  and adjustments to deductibles and out of pocket maximums.  Pre-existing conditions are not part of underwriting, and premium subsidies continue for 2020.  Individuals can enroll in state Medi-Caid programs anytime of the year.  Plans are available ON and OFF the Exchange.  If you do not need assistance paying for health insurance premiums our suggestions is enroll OFF Exchange which does not require income or employment verification.

Grandfathered plans (plans in place prior to 3-22-2010) will continue indefinitely for most insurance companies unless notified in writing 3-6 months in advance.  All non-grandfathered plans have been discontinued and members were mapped to a comparable plan by the end of 2015.  Premiums will increase each year for most plans and most insurance carriers.

Short Term Health plans may not meet the guidelines of the ACA and may not have all Essential Benefits. The number of providers of these plans has decreased the past 2 years. You may enroll in a short term health plan for up to 90 days without penalty in most states.

Some states have developed their own self managed Exchanges and some states will utilize the Federal Health Care Exchange for the first few years.

Those who lose their coverage or have a qualifying event can change coverage within 30-60 days of the event. Examples: marriage (30 days), birth or adoption of a child (30 days), lost of group coverage, moving from another state have a 60 day enrollment window.  Supporting documents for any event are required by the insurance companies.    

2015 Penalties:  The annual fee for not having insurance in 2015 is $325 per adult and $162.50 per child (up to $975 for a family), or 2% of your household income above the tax return filing threshold for your filing status – whichever is greater. 

2016 Penalties:  The annual fee for not having insurance in 2016 is $695 per person, $347.50 per child under 18, or 2.5% of your household income above the tax return filing threshold for your filing status – whichever is greater. If you are uninsured for more than 3 months despite having access to affordable coverage, you will be required to pay whichever amount is higher. (source:

2017 Penalties:  The annual fee for not having insurance in 2017 is $695 per person, $347.50 per child under 18, up to $2085 per family, or 2.5% of your household income minus the federal tax return filing threshold for your filing status. If you are uninsured for more than 3 months despite having access to affordable coverage, you will be required to pay whichever amount is higher (refer to exceptions such as hardship, unaffordable coverage options, incarceration, no tax filing, not lawfully present, religious conscience, health care sharing ministry, and American Indian tribes).  (sources: and  Previous OEP was Nov 1, 2016 - January 31, 2017.

2018 Penalties: Same as 2017.

2019 Penalties:  The penalites for having no health insurance has been discontinued. Federal and state level.

2020 Penalties:  Reestablished in Calfornia for 2020. See 2017 Penalties notes above. 


2017 Comments to ACA / Obamacare Changes:

For 2017 we saw rate increases in the individual market from 15-30% and the deductibles and out of pocket maximum values increase between $50 and $1000 (+/-).   I have been reading and searching out new articles as we see them in the headlines about Trump and other legislators comments and actions regarding repeal.... replace...changes to the Affordable Care Act/Obamacare. As of major changes will happen for perhaps 3-12 months. Perhaps there will be a slowing down of some updates to the ACA that were planned for 2017, 2018 and 2019. Those changes may be minor as not requiring by law that everyone have coverage or be penalized.  Some of the senators have written their own bills for repeals / or change that may change the amount of subsidy given to a person (say 55+) versus those younger (30 and less); give the states more power to deregulate health insurance, and change the amounts of deductibles that seem to be increasing.  It would be fair to all if positive constructive and financial changes were across the board for the consumer, the insurance company, the doctors, the agent, and pharmaceutical companies.
As I read today (January 21, 2017), the President cannot craft or pass legislation but can make suggestions for others to write their bills.  But he does have the right to veto.   

2018 Comments to ACA / Changes:

For 2018 we saw rate increase again in the individual market from 10-25% and the deductibles and out of pocket maximum values increase between $50 and $1000 (+/-).

The following is a excerpt is from

............But the lower enrollment volume in (2018) may have been due to the state’s approach to handling the Trump Administration’s decision to end federal funding for cost-sharing reductions (CSR). California was the first state to announce their decision to allow insurers to create slightly different off-exchange silver plans, and only add the cost of CSR to on-exchange silver plans. The state then actively encouraged unsubsidized silver plan enrollees to switch to off-exchange coverage, in order to protect those consumers from having to pay the higher premiums that were necessary to cover the cost of CSR. Consumers who get subsidies were encouraged to continue to shop in the exchange, where their subsidies increased to offset the higher premiums. Ultimately, several states took the same approach for 2018 premiums.

Covered California is one of ten state-run exchanges that uses an “active purchaser” model, meaning that they negotiate directly with carriers to make sure that rates, networks, and benefits are as consumer-friendly as possible (the remaining state-run exchanges and the federally-run exchange simply set minimum standards that carriers must meet, and then allow the sale of any plans that meet those guidelines).

Covered California is also the only exchange in the country that requires all health plans to be standardized, which means that within a single metal level, all plans have the same benefits (with the exception of HSA-qualified plans, which are also standardized but with benefits that are different from the other bronze and silver plans; Covered California’s board approves changes to the standardized HSA-qualified benefit design, as needed to comply with IRS regulations pertaining to HSA-qualified plans).

2018 legislation to watch

California lawmakers are considering several pieces of legislation in 2018 that would address health care reform in California. They include:

  • S.B.910: Would prohibit the sale of short-term health insurance plans as of January 1, 2019. The Trump Administration has proposed rolling back Obama Administration regulations that shortened the allowable duration of short-term plans. If finalized, the new rules would allow short-term plans to be sold with durations of up to 364 days. Individual mandate penalties apply when people rely on short-term insurance, but that penalty will be $0 as of 2019. S.B.910 is an effort to protect the state’s major medical individual market, and prevent short-term plans from siphoning off the healthiest members into lower-cost plans.
  • A.B.2499: Would increase the medical loss ratio minimum requirements in California by 5 percentage points. So large group plans would have to spend at least 90 percent of premiums on medical claims and quality improvements, while individual and small group plans would have to spend at least 85 percent. The Consumer Health Insurance Protection Act, introduced in the US Senate in March 2018 by Elizabeth Warren (D, Mass), would increase the medical loss ratio minimum to 85 percent for the individual and small group market, bringing them into line with the large group requirements.
  • A.B.2459: Would provide a state-based tax credit to offset the cost of individual market coverage that exceeds a certain percentage of the enrollee’s income. As of March 2018, the percentage of income has not yet been determined, but the legislation refers to the difficulties faced by people who have to pay more than 10 percent of their income for a bronze plan.
  • A.B.2416: Would require health insurance with Medi-Cal (Medicaid) managed care contracts to negotiate with Covered California regarding offering individual market plans via the exchange, in areas that are in the insurer’s Medi-Cal managed care service area and in which there would otherwise be two or fewer insurers offering plans. Covered California is an active purchaser exchange, which means that the exchange negotiates with insurers rather than simply accepting all insurers that want to offer products in the exchange.
  • A.B.2565: Would provide state funding to enhance the premium subsidies that are already available to eligible Covered California enrollees. Enrollees would continue to get federal subsidies, but the state would contribute funds as well, on a sliding scale based on income. Under current federal rules, people with income between 300 and 400 percent of the poverty level have to pay 9.56 percent of their income for a silver plan. Under A.B.2565, the state would contribute enough to reduce this to 8.16 percent. People with lower income would see similar reductions in the percentage of income they have to spend on a silver plan. Like the ACA’s subsidies, the state subsidies could be applied to plans at any metal level.
  • A.B.2965: Would expand Medi-Cal (Medicaid) to all income-eligible California residents, regardless of immigration status. The state would have to seek a waiver from the federal government in order to implement this provision. California considered similar legislation in 2015 (S.B.4), but the bill was amended so that it would only apply to children under the age of 19 (that provision is currently in effect; undocumented immigrant children in California are eligible for Medi-Cal if their household income makes them eligible). California also passed S.B.10 in 2016, which would have allowed undocumented immigrants to purchase full-price coverage in the exchange. The state sought federal approval for this provision, but ultimately withdrew their waiver amid concerns that the Trump Administration might use the state’s data for immigration law enforcement.
  • A.B.2472: Would allow people who aren’t eligible for Medicaid to buy into the Medicaid program. This would create a public health insurance option in California, operating alongside the private plans that are available for purchase. The state would have to seek a waiver from the federal government in order to implement the Medicaid buy-in program.
  • A.B.3148: Would prevent anyone with income below 250 percent of the poverty level from enrolling in a bronze plan. The bill would also enhance the ACA’s cost-sharing reductions, to make them more robust in California: People with income between 200 and 299 percent of the poverty level would be eligible for a plan with 87 percent actuarial value, while those with income between 300 and 400 percent of the poverty level would get a plan with 80 percent actuarial value. Under the ACA, cost-sharing reductions end at 250 percent of the poverty level, so A.B.3148 would extend cost-sharing reductions all the way to 400 percent of the poverty level in California.

2020 Updates

  • Increases in health insurance rates are stated to be minimal in 2020 by most California insurers.
  • Anthem will discontinue another block of Grandfathered plans by December 31, 2019.
  • Networks of doctors may again shrink in 2020. 
  • The Blue Card network for Anthem and Blue Shield individual health plans have been removed as of 2019. Consumers need to check their benefit options when traveling out of their state of residence.


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Make the Right Decision Today:

The value of having reliable health coverage shouldn’t be underestimated. There are multiple health insurance carriers that can be trusted, and provided affordable, flexible and dependable coverage.

You can’t afford to be without health coverage.
Health coverage helps protect you and your family physically and financially.

Because life is unpredictable.
Even if you are healthy now and exercise regularly, you could be caught off guard by an unexpected illness or injury.

Because medical care is expensive.

Cost of a typical Hospital stay (about 4 days and 2 follow-up visits):

$4,000 - Physician charges
$24,600- Hospital charges
$400 - Follow- up care
$29,000 Total

Services covered under most plans:

Doctor’s Visits
Physical Therapy
Preventative Care
Occupational Therapy
Emergency Room
Home Health Care
Skilled Nursing Facility
Well Child Care
Respiratory Therapy
Family Planning
Diabetes Care
Mental Health Services
Chemical Dependency Services
Durable Medical Equipment
Out-Patient Services
Out-of-State Services

Pediatric dental and vision benefits are embedded in ACA individual and group health plans.  These benefits are for children ages 0- 18. Request a copy of the benefit of summary to review details.

Contact us today for a free, no obligation, discussion regarding your needs. Contact Us >>