Frequently asked questions about health insurance
coverage options in California
California was the first state to authorize a state-run exchange under the Affordable Care Act. Covered California is widely regarded as one of the most successful established under the Affordable Care Act.
California enacted legislation in 2019 to create a state-based individual mandate and state-based premium subsidy program, both of which took effect in 2020.
The individual mandate has a non-compliance penalty that mirrors the federal penalty that was in effect in 2018.
California allocated $295 million in state funds to provide premium subsidies to people earning between 400 and 600 percent of the poverty level (ie, people who aren’t eligible for federal premium subsidies), as well as supplemental subsidies for enrollees with income between 200 and 400 percent of the poverty level.
Read our overview of the California health insurance marketplace – including news updates and exchange history.
California enacted legislation in 2019 that permanently sets open enrollment dates that differ from the rest of the country. California will continue to have a three-month open enrollment period, running from November 1 through January 31 each year.
As a result of the ongoing COVID pandemic, Covered California has opened a special enrollment period for uninsured residents, which runs from February 1 to May 15, 2021. And to give people access to the newly enhanced premium subsidies created by the Amerian Rescue Plan, Covered California is also offering an enrollment window from April 12 through December 31, 2021, for uninsured residents as well as people with off-exchange coverage.
Premium subsidies are not available outside the exchange, and California has an estimated 430,000 people enrolled in plans outside the exchange (directly through California’s insurance companies). Many of them may have income above 400% of the poverty level, which meant they were ineligible for premium subsidies altogether, regardless of how much they had to pay for coverage.
The ARP has eliminated the “subsidy cliff” for 2021 and 2022, so people with income above 400% of the poverty level can qualify for a premium subsidy if the benchmark plan would otherwise cost more than 8.5% of their household income. But they have to transition to the exchange in order to be eligible for the subsidy. Covered California and the state’s insurers have vowed to make this process as smooth as possible.
During the open enrollment period for 2020 coverage, 1.54 million people enrolled in private plans through Covered California.
About 1.57 million people had enrolled in 2021 coverage with a January 1 effective date, although the enrollment window continued through the end of January, likely adding to that enrollment tally.
California embraced healthcare reform, creating a state-based health insurance marketplace and expanding Medicaid. According to U.S. Census data, the uninsured rate in California dropped from 17.2 percent in 2013, to just 7.2 percent in 2018.
Covered California has also helped Californians lower their prescription medication costs. In 2016, the state exchange rolled out a cap on prescription costs. Available to consumers purchasing off-exchange plans as well, the cap is linked to the metal level of the plan purchased and is $250 per specialty medication per month for the majority of consumers.
California embraced the ACA’s Medicaid expansion in 2013, as then-Gov. Jerry Brown signed legislation that was expected to expand Medicaid coverage to over a million Californians.
Between fall 2013 and September 2020, enrollment in California Medicaid plans increased from about 7.75 million to more than 12.1 million – a 57 percent increase. California’s Medicaid program is by far the largest in the nation. (About 16 percent of the nation’s Medicaid enrollees are in California).
Officials had expected MediCal enrollment to grow to as much as 14.5 million people as a result of the widespread job losses stemming from the COVID-19 pandemic, but enrollment was hovering at about 12.5 million as of July 2020, and had dropped a bit by September, as some people were able to start returning to their jobs.
If you have questions, about Medi-Cal, visit the California Department of Health Care Services website. Note: California’s Children’s Health Insurance Program (CHIP) was previously known as Healthy Families. In 2013, California transitioned Healthy Families enrollees to Medi-Cal.
Read more about California’s Medicaid expansion.
California’s lawmakers passed a bill in 2018 that prohibits the sale or renewal of short-term health insurance plans in California as of January 1, 2019. (The sale of other non-ACA-compliant plans, such as fixed indemnity products and critical illness plans, continues to be allowed.)
Read more about short-term health insurance in California.
There were 6,454,217 California residents enrolled in Medicare plans as of December 2020. About 46 percent were enrolled in Medicare Advantage plans, while the other 54 percent were enrolled in Original Medicare.
Read more about Medicare in California, including the state’s rules for Medigap plans.
Prior to the ACA’s reforms in the individual health insurance market, medical history was a factor in eligibility for private plans in nearly every state, including California. Applicants with pre-existing conditions were often unable to buy individual plans in the private market, or if coverage was available it came with a higher premium or with exclusions on pre-existing conditions.
The California Major Risk Medical Insurance Board (MRMIB) was created in 1991 to provide a coverage option for people who were ineligible for coverage under a private plan because of medical history.
Under the ACA, all new health insurance policies became guaranteed issue starting on January 1, 2014. This change largely eliminated the need for high-risk pools, since pre-existing conditions are no longer a barrier to obtaining coverage.
The California Budget Act of 2014 included a provision for MRMIB to cease operations as of July 1, 2014. Most of the MRMIB insureds had already been able to obtain coverage through the exchange or expanded Medicaid, but remaining members were transitioned to the California Department of Health Care Services on July 1.