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Covered California Q&A

Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

Exchange vs Off-Exchange Plans?

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Question: I understand that insurance companies can offer off-exchange plans, in addition to the ones on the exchange. Will those be different from the plans offered on the exchange? In what ways are they allowed to differ? Why aren’t they all on the exchange? I will not qualify for a tax credit (subsidy), so I will have the option of looking either on- or off-exchange, when I shop for new individual coverage, is that correct?

Answer: Yes you will have the option of choosing either a Covered California or off-exchange health plan. I don’t really know how different the off-exchange health plans offered in California will be. There are guidelines imposed by the ACA and California state laws that will minimize the difference. Specifically, off-exchange plans will have to conform to 4 metal tiers of benefits with minimum actuarial values. They will also have to meet minimum coverage requirements called essential benefits. For example, the off-exchange plan will have to include maternity coverage just as the exchange plans do. On the other hand, those carriers that are not included in the Covered California exchange either by choice or not making the cut, will offer off-exchange plans. In as much as they are outside the influence of Covered California, they will seek whatever competitive advantage federal and state laws allow. We’ll have to wait to see what they might come up with.


If I have ESRD, can I apply for an off exchange plan and keep my Medicaid benefits?

Covered California plans are only offered “on the exchange”. Off-exchange plans that mirror the Covered California plans are supposed to have the same provider networks - notwithstanding comments to the contrary. You must select your employer-based plan (when you have the opportunity to enroll) over a Covered California plan.

Am I correct to assume that the exchange simply means the California covered plans? Off the exchange means doctors that are not within the California cover plans? can I choose between a California cover the pan and my employee offered Plan?Thank you.

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