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FAQ: Covered California's next open enrollment begins Saturday

Covered California Executive Director Peter Lee.
Covered California Executive Director Peter Lee.
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California’s second health insurance enrollment period under the Affordable Care Act begins tomorrow. The three-month window marks the only time – except in the case of "qualifying life events" such as getting married or changing jobs – that a person can buy individual or family insurance for 2015.

Health policy experts say now is the time to shop and compare for the nearly 1.2 million Californians who bought 2014 insurance through Covered California, and for those who bought individual plans outside the exchange. 

Those who do nothing will be automatically enrolled in their existing plan.

"Pay your premium in December and you’re good to go on Jan. 1," says Peter Lee, Executive Director of Covered California. "But we encourage people to shop and see if there is a better option for them."

And that's advice you'll want to follow, even if your existing plan is working well for you, says Larry Levitt, insurance expert and senior vice president at the nonprofit Kaiser Family Foundation. 

"People need to look really carefully at the lineup of plans going into next year," he says.  "Because if they go on auto pilot and just let their insurance renew, they could find themselves in a much more expensive plan than they want to be."

That’s because while average premium prices for plans sold through Covered California are only rising a modest 4.2 percent statewide, the premiums of some 2015 plans changed quite dramatically.  

For example, in parts of Los Angeles county, Anthem Blue Cross is charging up to 16 percent more in 2015 for one of its plans. Conversely, in that same region Kaiser Permanente is charging 14 percent less for one of its plans. 

So how do you figure out what’s best for you?

Peter Lee says, ask for free help.

"We have across the state 25,000 people," he says, "certified insurance agents, certified enrollment counselors, county workers – that can help people work through the right plan, the right benefit design."

To help you navigate your insurance choices, here are answers to eight commonly asked questions:

1.  How long does Open Enrollment last?

The open enrollment period for 2015 begins on November 15, 2014 and ends on February 15, 2015. But you need to switch plans or buy your plan by December 15, if you want it to take effect on January 1, 2015.  

2. Do I need to buy my plan through Covered California?

Not necessarily. If your income qualifies you for federal tax subsidies, the only way you can get them is to buy your plan through Covered California. But if you don’t qualify for subsidies or the plans offered through the exchange are not what you want,  you’ll likely find it a lot easier to buy your policy directly from a health insurer. In either case, you can seek help from a certified insurance broker, who charges nothing to assist consumers.

3. How do I get financial help to pay for my health insurance premium?

If your income is less than 400 percent of the federal poverty level, you may qualify for a tax subsidy. You can take this subsidy in one of two ways: up front to offset the cost of your premium each month, or at the end of the year.  And even if you’ve decided you like your plan and you’re fine with being automatically re-enrolled in it next year, you should take a moment to re-calculate your income. That way you’ll get the correct subsidy and not be faced with repaying any portion of it, if you receive too large of one.

4. How can I tell if my doctor or hospital is on my plan?

Unfortunately, there's no sure-fire way to do this. In the absence of a comprehensive doctor directory on the Covered California website,  Levitt and others say you'll want to check both with your provider and with your insurance plan.  And don’t assume just because your doctor is covered by your 2014 health plan that the same will be true come 2015.

"This is a case where double and triple checking is the smart thing to do," Levitt says.

Failing to do so could leave you holding the entire bill for any treatments you receive from providers outside your network.

5.  Does a low monthly premium mean I’m getting a good deal?

Not necessarily. There’s a whole category of other "out of pocket" costs, known as "cost-sharing" that include things like your deductible, co-pays, co-insurance. 

And when you buy a policy, the amount of cost-sharing will be determined by which type of plan you buy. Today’s health plans are grouped into metal tiers.  A cheaper bronze plan has the lowest premiums – but the highest amount of cost-sharing. And on the flip side,  a top-tier platinum plan is the most costly each month, but it covers more of your out-of-pocket expenses that lower-tiered plans.

So if you are a heavy user of health services, you may want a high-end gold or platinum plan.  And if you’re healthy and don’t need much medical care, a bronze or  silver plan may be just what the doctor ordered. 

6. What else do I need to consider when determining whether a particular plan will work for me?

You’ll want to make sure you know how much a particular plan will pay toward any prescription medications you take.  Some drugs can be far more expensive than others and if you’re enrolled in a bronze plan, for instance,  you could see some steep out of pocket co-pays.  A broker or enrollment counselor can help you figure out what plan works best with your prescription needs.

7.  Is an EPO (Exclusive Provider Organization) a good option for me?

The EPO or Exclusive Provider Organization is a somewhat new animal in the health insurance world.  It’s a sort of hybrid between the traditional PPO and HMO. 

Like a Heath Maintenance Organization (HMO), an EPO requires you to stay in network. Going out of it means you’ll pay out of pocket for care. And, thus, the term "exclusive" refers not to some cool, added premiums, but rather to the limitations of the network.

Like a Preferred Provider Network (PPO), an EPO allows you to see doctors without requiring you first get a referral from your primary care physician.

In parts of southern California, some of the larger health plans on the exchange are selling only EPOs.  So make sure you understand the differences among EPOs, PPOs, and HMOs before you enroll or re-enroll in one of them.

8. What happens if I go uninsured in 2015?

If you are eligible for coverage and don’t have a valid exemption, you’ll face a tax penalty.  This year it climbs to $325 per adult and $162.50 per child or 2 percent of your income, whichever is greater.

But, as Peter Lee points out: "The big penalty isn’t needing to write a check to the IRS. The big penalty is needing to show up at the emergency room and walking out with a $400,000 debt…that’s the penalty we want Californians to avoid."