Individual & Family Health Insurance CA

What is Individual & Family Health Insurance?

Individual and family health insurance is coverage you purchase directly for yourself and your dependents, rather than receiving it through an employer.

In California, individual and family plans are primarily available through Covered California, the state's official health insurance marketplace. These plans offer the same comprehensive coverage and consumer protections as employer-sponsored plans, including coverage for pre-existing conditions and essential health benefits.

Individual/Family vs. Employer Group Coverage

Feature	Individual/Family Plans	Employer Group Plans
Who Pays	You pay full premium (minus subsidies)	Employer typically pays 50-80%
Subsidies Available	Yes, based on income	No
Plan Choice	You choose from all available plans	Limited to employer's offered plans
Coverage Portability	Keep if you change jobs	Lose when you leave job
Enrollment Period	Once yearly + special events	During employer's enrollment period

Who Should Get Individual & Family Coverage?

Individual and family health insurance is ideal for Californians who don't have access to affordable employer-sponsored coverage. This includes:

Self-Employed & Business Owners

Freelancers, contractors, sole proprietors, and small business owners without employer coverage. You can deduct health insurance premiums as a business expense.

Between Jobs

Unemployed, laid off, or in career transition. Don't wait—you can enroll within 60 days of losing employer coverage through a Special Enrollment Period.

Part-Time Workers

Working part-time, as a gig worker, or in a position that doesn't offer health benefits. Many part-time workers qualify for substantial subsidies.

Early Retirees

Retired before age 65 when Medicare begins. Covered California plans bridge the gap until you're Medicare-eligible.

Unaffordable Employer Coverage

Employer offers coverage but it costs more than 9.12% of your household income. You may qualify for subsidized coverage through Covered California instead.

Inadequate Employer Coverage

Employer plan doesn't meet Minimum Essential Coverage standards. You can switch to Covered California for comprehensive coverage. Learn about MEC standards.

Types of Plans Available

Covered California offers plans in four metal tiers, each providing the same comprehensive benefits but with different cost-sharing structures.

Bronze 60% Coverage

Lowest monthly premium
Highest out-of-pocket costs when you get care
Best for: Healthy individuals who rarely see doctors
Good option if you want catastrophic protection

Silver 70% Coverage

Moderate monthly premium
Balanced out-of-pocket costs
Best for: Most people—the "sweet spot"
Eligible for Cost-Sharing Reductions (CSR) if income qualifies

Gold 80% Coverage

Higher monthly premium
Lower out-of-pocket costs when you get care
Best for: People with chronic conditions or who see doctors frequently
Good value if you use healthcare services regularly

Platinum 90% Coverage

Highest monthly premium
Lowest out-of-pocket costs when you get care
Best for: High healthcare usage, complex medical needs
Maximum coverage and predictability

Enhanced Silver Plans (73%, 87%, 94%)

If your household income is between 100-250% of the Federal Poverty Level, you may qualify for Enhanced Silver plans with even better coverage (73%, 87%, or 94%) at Silver plan prices. This is often the best value available. Learn about income requirements.

Catastrophic/Minimum Coverage: Available only to individuals under 30 or those with a hardship exemption. Very low premiums but high deductibles—only covers essential benefits after you meet a high deductible.

Compare All Plan Tiers Side-by-Side

How Much Does It Cost?

Most Californians qualify for financial help that significantly reduces monthly premiums and out-of-pocket costs.

Premium Tax Credits (Subsidies)

Premium tax credits reduce your monthly health insurance premium. Here's how they work:

Who qualifies: Households with income between 138% and 600% of the Federal Poverty Level (roughly $20,000-$90,000 for individuals, $41,000-$185,000 for a family of 4 in 2025)
How much you save: Varies based on income—some pay $0/month for Silver plans
How to get them: Applied automatically when you enroll through Covered California
Paid directly to insurer: Reduces your monthly bill immediately

Example: 35-year-old in Los Angeles

Income: $35,000/year

Full price: $450/month
With subsidy: $100-150/month
Saves: $3,600-4,200/year

Income: $25,000/year

Full price: $450/month
With subsidy: $0-50/month
Saves: $4,800-5,400/year

Cost-Sharing Reductions (CSR)

Available only with Silver plans for households earning 100-250% FPL. CSR reduces:

Deductibles (amount you pay before insurance kicks in)
Copayments (fixed amount per doctor visit, prescription, etc.)
Coinsurance (percentage you pay for services)
Out-of-pocket maximums (your yearly spending cap)

Calculate Your Actual Cost

See exactly what you'll pay based on your income, age, and household size.

Calculate My Subsidy Now

What's Covered? Essential Health Benefits

All individual and family plans sold through Covered California must cover the 10 Essential Health Benefits defined by the Affordable Care Act. The metal tier (Bronze, Silver, Gold, Platinum) only affects how costs are shared—not what's covered.

1. Preventive & Wellness Care

Annual checkups, immunizations, screenings, counseling—all at no cost to you (no copay, no deductible).

2. Doctor Visits

Primary care, specialist visits, urgent care. Typically require copay or coinsurance after deductible.

3. Emergency Services

ER visits, ambulance transport. Covered even if out-of-network. No prior authorization required.

4. Hospitalization

Inpatient care, surgery, room and board. Usually requires coinsurance after meeting deductible.

5. Prescription Drugs

Generic and brand-name medications. 4-tier formulary with different copays/coinsurance per tier.

6. Laboratory Services

Blood tests, urinalysis, cultures, pathology. Preventive labs covered at no cost.

7. Mental Health & Substance Abuse

Therapy, counseling, inpatient and outpatient treatment. Must be covered at parity with physical health.

8. Maternity & Newborn Care

Prenatal visits, delivery, postpartum care, newborn care. Cannot be excluded or charged extra.

9. Pediatric Services

Well-child visits, pediatric dental and vision care (for kids under 19). Dental/vision included in medical plan.

10. Rehabilitative Services

Physical therapy, occupational therapy, speech therapy. Helps you recover function after injury or illness.

Important Consumer Protection: All plans cover pre-existing conditions. You cannot be denied coverage or charged more due to your health history.

Eligibility & How to Enroll

Who Qualifies for Covered California?

California resident (live in CA, intend to stay)
U.S. citizen or lawfully present immigrant
Not currently incarcerated
Not eligible for Medicare, Medicaid (Medi-Cal), or affordable employer coverage

When Can You Enroll?

Open Enrollment

November 1 - January 31 every year

Coverage starts January 1 (or February 1 if you enroll after December 15)

Special Enrollment

Within 60 days of a qualifying life event:

Lost health coverage (job loss, aged out)
Got married or divorced
Had a baby or adopted
Moved to California
Became a citizen

Documents You'll Need

Social Security numbers for all family members
Proof of income (pay stubs, tax return, W-2, 1099)
Immigration documents (if applicable)
Current insurance information (if any)

Get Free Enrollment Help

Our certified enrollment counselors can:

Explain your coverage options in plain language
Help you compare plans and find the best fit
Complete your application accurately
Ensure you get all subsidies you're eligible for
Provide ongoing support for life changes

Contact an Enrollment Counselor

Individual vs Family Coverage: What's the Difference?

Individual Plan

Covers: Just you (one person)

Ideal for:

Singles without dependents
Individuals whose family has other coverage
Young adults up to age 26 on parent's plan

Cost: Lower monthly premium since it's only one person

Deductibles/OOP Max: Individual amounts apply

Family Plan

Covers: You + spouse + dependent children (under 26)

Ideal for:

Married couples
Parents with children
Households needing coverage for 2+ people

Cost: Higher premium but covers entire household under one plan

Deductibles/OOP Max: Family amounts (usually 2x individual)

Can You Add or Remove Family Members Later?

Yes! You can add family members within 60 days of a qualifying event (marriage, birth, adoption). You can also remove members (divorce, child ages out) during Special Enrollment or Open Enrollment. Changes to your household may also affect your subsidy amount.

Cost Comparison Example

Coverage Type	Who's Covered	Typical Premium (Silver 70)	Family Deductible
Individual Only	35-year-old adult	$450/month	$4,500
Couple	35-year-old + spouse	$900/month	$9,000
Family of 4	2 adults + 2 children	$1,350/month	$9,000

*Estimates before subsidies. Actual costs vary by age, location, and carrier. Most families receive substantial premium assistance.

Choosing the Right Plan for Your Family

The best plan depends on your health needs, budget, and preferences. Consider these factors:

Key Questions to Ask:

How often do you visit doctors?

Rarely: Bronze plan (low premium, high deductible)
Occasionally (1-3 times/year): Silver plan (balanced)
Frequently: Gold or Platinum (higher premium, lower per-visit costs)

Do you take regular medications?

Check each plan's formulary (drug list) to ensure your medications are covered. Higher metal tiers usually have lower prescription copays.

Do you have preferred doctors or hospitals?

Make sure your providers are in-network for the plan you choose. Out-of-network care costs significantly more or isn't covered at all (HMO plans).

What's your budget?

Balance monthly premium affordability with potential out-of-pocket costs. Don't just look at premium—consider deductibles and copays for your expected healthcare usage.

What's your income?

If you qualify for Cost-Sharing Reductions (100-250% FPL), Enhanced Silver plans offer the best value—often better than Gold at a Silver price.

Compare Plans Now Calculate My Costs

Frequently Asked Questions

Yes, but only during a qualifying event. You can add family members within 60 days of marriage, birth, adoption, or other qualifying events. Changes take effect the day after the event (for births/adoptions) or the first of the following month (for marriages). You'll need to report the change to Covered California.

Having a baby qualifies you for a Special Enrollment Period. You have 60 days to add the newborn to your plan (or switch to a family plan if you have an individual plan). Coverage for the baby is retroactive to the date of birth. Your premium and subsidy will also be recalculated based on the larger household size.

Most people do! If your household income is between 138% and 600% of the Federal Poverty Level and you don't have access to affordable employer coverage or public programs like Medicaid/Medicare, you likely qualify. The exact amount depends on your income, age, location, and household size. Use our subsidy calculator to find out.

It depends on whether your doctor is in the plan's network. Before enrolling, use the plan's provider directory to verify your doctors are in-network. HMO plans require your doctor to be in-network. PPO plans allow out-of-network care but at higher costs. Most Covered California plans have robust networks, but always check first.

Report income changes to Covered California within 30 days. Your subsidy will be adjusted to match your new income, increasing if you earn less or decreasing if you earn more. This prevents owing money back at tax time (if subsidy was too high) or missing out on savings (if subsidy should be higher). You can report changes online through your Covered California account.

You can switch plans during Open Enrollment (November 1 - January 31) each year. Outside of Open Enrollment, you can only switch if you have a qualifying life event or move to a different coverage area. If you qualify for a Special Enrollment, you can choose any available plan, not just from your current carrier.

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Individual & Family Health Insurance in California