Components of Plans in Covered California
Individual and Family Plans through Covered California are unique in that there are three components that have to be considered when applying for coverage.
- Tax benefits that you get through Covered California are based on your Federal Poverty Level (FPL) percentage. There are three components
- Advanced Premium Tax Credit (APTC). This is dollars that will be sent directly to the insurance company you choose to cover your medical expenses, after which the insurance company will bill you the net amount. The federal government helps those whose FPL percentage is between 138% and 400%
- Cost Share Reduction (CSR). The government helps fund the internal out of pocket expense for copays, coinsurance, and maximum out of pocket for those whose FPL percentage is between 138% and 266%. Only the Silver Tier gets this treatment.
- State Tax Subsidies. In California, beginning Jan 1, 2020, the state will help those whose FPL percentage is between 401% and 600%.
- Tax forms.
- 1095A: The form you get from Covered California to give to your tax advisor to reconcile your APTC with your true taxable income.
- 8962: The form generated by your tax advisor to file with the IRS. It compares your APTC to the Premium Tax Credit you should have received based on your accurate taxable income. The completed form should be included in your copy of your tax return.
- Plan design concepts.
- Deductible: First dollars out of pocket before your plan pays
- Coinsurance: Percentage out of pocket you pay. With some plans this is after the deductible
- Out-of-Pocket Maximum/Limit. The most you would pay out of pocket annually. After you hit this limit, the plan pays 100% of your medical bill for any medical treatment you will receive.
- Metal Tiers: Bronze, Silver, Gold, Platinum. Coverage will vary depending on Metal Tier.
What you’ll need to enroll
- Proof of current household income
- California ID or Drivers License for adults
- Proof of lawful presence, e.g. Permanent Resident Card (Green Card), Employment Authorization Card, Visa or Passport. All documents must be current and valid.
- Birthdate for every person on the application
- Social Security number or Individual Tax Identification Number (ITIN) for every person on the application
- Home address and phone number
Please note that Medi-Cal recipients who want to purchase health insurance through Covered California will not qualify for APTC.
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