What Obamacare Means for Individuals and Employees in California

For many people, the implementation of the PPACA won’t affect their health care coverage. Most individuals covered by Medicaid (Medi-Cal), Medicare or employer group plans will not see any change to their plans. This means that roughly 80 percent of Americans will see no changes in their coverage.

For those without coverage, the Affordable Care Act means they must seek out private insurance, buy insurance from their employer or risk paying the individual mandate penalty. Subsidies are widely available for individuals and families with incomes up to four times the poverty level, which includes income up to $45,960 for an individual or $94,000 for a family of four in 2014.

What Are Essential Health Benefits Under Obamacare In California?

There are no annual limits that can be placed on essential health benefits, which cover the following areas of care:

  • Outpatient care
  • Emergency services
  • Hospitalization
  • Maternity and newborn coverage
  • Mental health
  • Prescription drug benefit
  • Rehabilitative services
  • Laboratory services
  • Preventive and wellness services
  • Chronic disease management
  • Pediatric services

These core services must be covered under any individual or small group plan, though this does not apply to grandfathered plans.

When the Individual Mandate Doesn’t Apply

If the following cases, the individual mandate doesn’t apply and you do not have to purchase private insurance through an exchange or pay a penalty:

  • It’s against your religion
  • You’re an undocumented immigrant
  • You are incarcerated
  • You are part of a Native American Tribe
  • Family income is low enough that you do not have to file a tax return
  • Health insurance would cost more than 8% of your income
  • You’ve been grandfathered in through an existing plan that has been continuously active since March 23, 2010
  • There is no penalty for a 3 month coverage gap within a year

Covered California and the Health Insurance Marketplace

The Affordable Care Act will create health insurance marketplaces in each state in 2014. If you choose not to get insurance through an employer, you  can choose from several different options directly from the insurance companies which offer plans through the state exchanges.

In California, the marketplace is called Covered California and includes the following providers:

  • Kaiser Permanente
  • Anthem Blue Cross
  • Blue Shield of California
  • Health Net
  • Alameda Alliance for Health
  • Chinese Community Health Plan
  • Contra Costa Health Services
  • L.A. Care Health Plan
  • Molina Healthcare
  • Sharp Health Plan
  • Valley Health Plan
  • Ventura County Health Care Plan
  • Western Health Advantage
Opt Out Penalties For Individuals and Families

This is how the yearly penalties will be assessed over the next several years for those who opt to go without insurance and pay the penalty:

  •  2014 – $95 per adult, $47.50 per child, with a cap of one percent of family income or $285, whichever amount is higher
  •  2015 – $325 per adult, $162.50 per child, with a cap of two percent of family income or $975
  •  2016 – $695 per adult, $347.50 per child, with a cap of 2.5 percent of income or $2,085 per family.
  •  2017 – increases in line with inflation and children will be half the cost of the adult penalty

Though there are some exceptions, the 2014 changes to the Affordable Care Act also mean that all parties applying for insurance must be accepted, regardless of preexisting medical conditions.

Written by Todd Taylor

Todd Taylor

Todd Taylor oversees most of the marketing and client administration for the agency with help of an incredible team. Todd is a seasoned benefits insurance broker with over 35 years of industry experience. As the Founder and CEO of Taylor Benefits Insurance Agency, Inc., he provides strategic consultations and high-quality support to ensure his clients’ competitive position in the market.

We’re ready to help! Call today: 800-903-6066