Is it Right for You?

Almost everyone should be able to get health coverage. The question is, which plan is right for you and your family?

This page looks at options you may have, such as getting public health coverage, like Medi-Cal or Medicare, or getting health insurance through your job. If these options are available to you, they are better choices than getting an individual plan, because they cost less.

Then, we’ll look at why you might choose to get an individual plan. We’ll focus on getting a plan through Covered California, the easiest place for most people to shop for an individual plan and the only place where you can get help from the government to pay for your private insurance (if you qualify).

Other options that are probably better

The best way to figure out if buying an individual health plan is the right option for you is to sign up for Covered California and complete an application. Covered California will tell you what health coverage options are open to you. If you have any of the options below, don’t pay for private insurance through Covered California.

Public health coverage

There are several public health care programs that help people with disabilities, seniors, children, and anybody who has low income. If you or a family member qualifies for these programs, they are usually your best option and you will not be allowed to purchase a government-subsidized individual plan through Covered California.

Medi-Cal

Medi-Cal is a major government-funded health program that helps people with low income. You may qualify for Medi-Cal if you are in one of these situations:

  • Your family’s income is at or below 138% of the Federal Poverty Level (FPL) ($16,753 for an individual; $34,638 for a family of four). There are no limits to how much money or other resources you have. This is the most common type of Medi-Cal. You can read more about this in DB101’s Medi-Cal article.
  • You are a child 18 or younger and your family’s income is at or below 266% of FPL ($66,766 per year for a family of four).
  • You are pregnant, and your family’s income is at or below 213% of FPL ($35,060 if you are single and pregnant with your first child, $53,463 per year for a family of four, including the baby).
  • You have a disability or are elderly:
Health Coverage Income Limits for Your Family
Medi-Cal and immigrants
  • Undocumented immigrants do not qualify for full Medi-Cal coverage, though they may qualify for Medi-Cal coverage for emergencies or during pregnancy.
  • Some non-citizens who have legal immigration status in the United States do not qualify for full Medi-Cal coverage. However, if their income is at or below 400% of the Federal Poverty Level (FPL), they can qualify for government help paying for individual coverage.
  • Immigrants who have been legal residents for 5 years or longer or meet specific noncitizen requirements qualify for all of the same programs that citizens can get.

If you are not sure whether you qualify, contact an organization in your area that works with immigrants.

Medicare

Medicare is a health insurance program run by the federal government that covers seniors (65 years old or older) and people with disabilities. In order to get health coverage through Medicare, you must have worked for a certain number of years and met other eligibility rules, detailed in DB101’s Medicare article.

If you get Medicare, you cannot get government help with paying for an individual health plan. You could still buy an individual plan through Covered California, but you would have to pay the entire premium yourself. Also, if you want more coverage than what Medicare offers, it is probably better for you to look into whether you might also qualify for Medi-Cal based on having a disability or being elderly, which would help pay your Medicare premiums and other Medicare expenses. Another option is to look at getting a Medicare supplement policy (sometimes called a Medigap policy) or signing up for a Medicare Advantage plan. These options are not available through Covered California.

The bottom line about public health coverage options

If you or members of your family are eligible for a public program, that public program is probably your best option. If you think you might be eligible for a public program, see the other articles in DB101’s Health Care Coverage section.

Group coverage through your employer

To get private health insurance, a monthly payment called a premium must be paid every month. Many employers offer to pay part, or all, of this monthly premium as a job benefit for you as an employee, your children until they turn 26 years old, and your spouse.

If your employer offers you health coverage that would cost you, for your policy alone, less than 9.5% of your income and that coverage meets bronze-level standards, neither you nor your family will qualify for government help via tax subsidies to reduce the premium on an individual plan. That means that if you decide to purchase an individual health plan, you will have to pay the full premium, which will probably be more than you would pay if you used the coverage provided by your employer. To learn more about employer-sponsored health coverage, read DB101’s article about it.

Medi-Cal and employer-sponsored coverage

If your family makes 138% of the Federal Poverty Level or less, you can choose to get Medi-Cal through Covered California even if your employer offers coverage.

Note: If you work and have been determined disabled according to Social Security rules, you may be able to get coverage through Medi-Cal's Working Disabled Program. Talk to a Benefits Planner to learn more about Medi-Cal's Working Disabled Program.

The bottom line about group coverage through your employer

If your employer provides health coverage, you should not get an individual plan for yourself or your family. In most cases, the group coverage will be your best option.

However, if your income is at or below 138% FPL of the Federal Poverty Level or if you have a disability, it could be a better choice for you to get Medi-Cal for your entire family. In some cases it may even make sense to get employer-sponsored coverage for the adults in your family and get Medi-Cal for the children.

When an Individual Plan is Your Best Option

You should get an individual plan through Covered California if you cannot get health coverage from:

  • Your job
  • Your spouse’s job
  • Your parent’s job
  • Medi-Cal, or
  • Medicare

If you cannot get health coverage from any of the above options and your family’s income is at or below 400% of the Federal Poverty Level (FPL), $48,560 for an individual ($100,400 for a family of four), the government will help you pay your monthly premium via a tax credit. If your family’s income is at or below 250% of FPL, $30,350 for an individual ($62,750 for a family of four), the government will also help you get a plan that has lower copayments and other expenses.

When Covered California looks at your income, they will count most types of earned and unearned income you have. However, some income is not counted, including Supplemental Security Income (SSI) benefits and some contributions to retirement accounts. Learn more about what types of income affect whether you get help paying for individual coverage.

Later, we’ll go into more detail about how much you you’ll have to pay.

Health Coverage Income Limits for Your Family
Example

Clarence and Samuel have two small children and live in a two-bedroom apartment. Clarence is 37 years old and makes $45,000 per year as a freelance writer, while Samuel is 42 years old and makes $30,000 per year running his own small bakery, so their combined income is $75,000 per year. Since both of them are self-employed, they cannot get employer-provided coverage and their combined income is 299% of the Federal Poverty Level (FPL), meaning that they and their children don’t qualify for Medi-Cal.

They went to Covered California and found a plan that would cover their entire family. Since the government would help pay for their premium, this plan would cost them less than $500 a month. It wasn’t totally free, but it was a pretty good deal and they were satisfied.