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ACA Information for Individuals


Health Care Reform's Affordable Care Act 

Information for Individuals

Here is an Overview of Reform on all Individual Plans. 

On March 23, 2010 the Patient Protection and Affordable Care Act (PPACA) 2010 HR3590, or Affordable Care Act (ACA) for short, is the new health care reform law in America and is often called by its nickname Obamacare. The Patient Protection and Affordable Care Act is made up of the Affordable Health Care for America Act, the Patient Protection Act, and the health care related sections of the the Health Care and Education Reconciliation Act and the Student Aid and Fiscal Responsibility Act. It also includes amendments to other laws like the Food, Drug and Cosmetics Act and the Health and Public Services Act. Since being signed into law, additional rules and regulations have expanded upon the law. The new law impacted the Individual Plan Marketplace from the date of passage and mostly impacted All Health Plans since January 1st 2014.  

 Currently there are 2 Individual Plan Coverage Types;

Grandfathered Individual Plans:

If you purchased your plan prior to March 23, 2010 and stayed with the same Named Plan then your plan is most likely Grandfathered from certain ACA provisions and are exempt from certain mandated benefits and do not include the HCR Essential Health Benefits.  These Plans are CLOSED to new enrollments.

 ACA Individual Non-Grandfathered Plans:

If you purchased your plan after March 23, 2010 you are not exempt from certain mandated benefits and include the HCR Essential Health Benefits.  These Plans are OPEN to new enrollments.

The New ACA Qualified Health Plans

The ACA requirements began in 2014 for All New Individual Plans to have certain Qualified Health Plan Standardizations across All States.  The 3 Coverage Standards are Actuarial Value, Essential Health Benefits and Maximum Out-of-Pocket requirements.   Actuarial Values are arranged in 4 Tiers by the percentage of total average costs they cover for specific benefits as illustrated below.   

Coverage Tiers

Actuarial Value Levels

Benefits required

Required limitations


90% (+/-2% = 88%-92%)

Essential Health Benefits

Maximum Out-of-Pocket


80% (+/-2% = 78%-82%)

Essential Health Benefits

Maximum Out-of-Pocket


70% (+/-2% = 68%-72%)

Essential Health Benefits

Maximum Out-of-Pocket

Bronze Minimum Value

60% (+/-2% = 58%-62%)

Essential Health Benefits

Maximum Out-of-Pocket

 There is an exception for Individual Plans for individuals under age 30 and financial hardship which has a 5th class called Catastrophic.  

 All Individual and Small Group Plans must meet Maximum Out-of-Pocket 2020 Requirements.

2 Marketplaces to purchase Individual Plans

Since October 1st 2013 an additional New Marketplace was opened to accept Individuals and Small Business Groups.  See the comparison below for the difference between the Traditional Open Market to the New Marketplace called Covered California.


What are the differences?



Off Exchange

?         Current way to purchase your 

Individual and Small Group Health Plans

?         Open Market Health Plans are different from CoveredCA

?         Open Market Plans can be purchased from JIA Insurance  




On Exchange

?             Additional way to purchase your 

Individual and Small Group Health Plans

?         CoveredCA Health Plans are different from Open Market

?         CoveredCalifornia can be purchased from JIA Insurance Services

The differences from the Covered California Market?

?       Additional Health Plans will be available from the Health Insurance Carriers not offered in Covered California

?       Individual and Employer Tax Credits will not apply to the Open Market Plans

The differences from the Open Market?

?       Additional Health Plans are not available and is only offered in the Open Market.

?       Individual and Employer Tax Credits will only be applied to Covered California Market Plans.*


You may qualify for Premium Savings with Tax Credits and Cost-Sharing Subsidies based on your Household Total Income


·         Here is some important information about Tax Credits and Cost-Sharing Subsidies for Individuals. 

·         See if you qualify for any credits or subsidies based on your Household Total Income. 

·         This will determine which Marketplace you purchase a New Individual Plan

1. Tax credits: Tax credits will be available to help lower the cost of your monthly health insurance premium.

2. Cost-sharing subsidies: Cost-sharing subsidies reduce the amount of health care expenses an individual or family has to pay at the time of medical care.

3. Medi-Cal assistance: Starting in 2014, Medi-Cal will cover more people under age 65, including people with disabilities and those with low incomes. The coverage is free for those who qualify and is part of the provisions of the Affordable Care Act.


Qualifying for Tax Credits

Tax credits are available for individuals and families who meet certain income requirements and do not have access to affordable health insurance that meets minimum coverage or the affordability standards offered through their employer or another government program. Eligibility for tax credits is based on a standard, called the federal poverty level, based on family income and size. The size of the tax credit is based on a sliding scale, with those who make less money getting larger financial support to lower the cost of their insurance coverage. Individuals and families who make between 138 percent and 600 percent of the federal poverty.


Here are some key facts about tax credits.

·         Tax credits lower the cost of your premium. Tax credits reduce the amount you will pay for insurance.

·         Tax credits help low- and middle-income individuals and families. Tax credits are available to individuals and families who meet certain income requirements.

·         Tax credits can be applied to the cost of your health plan when you enroll. You do not need to wait until you file a tax return at year end.

·         Tax credits are only available through Covered California. You must enroll in a health plan through Covered California if you want to use your tax credits.

·         Tax credits are paid to your health plan. These tax credits are paid by the federal government each month directly to the health plan you choose through Covered California.




Starting January 1st 2020, California will provide New State Subsidies additional to the Federal ACA Affordability Care Act Subsidies to more Californians towards their Individual Health Plan.  The New State Subsidies will be provided through CoveredCA and extending eligibility for financial help up to 600% of the FPL Federal Poverty Level.  The amount of financial help consumers receive will vary depending on their age, their annual household income and the cost of health care in their region. The program will limit how much eligible Californians will pay for their premium as a percentage of their income. For example, older individuals living in regions with high health care costs could receive significant amounts of financial help, while some younger consumers in lower-cost regions may already be able to purchase a benchmark plan for less than the share of income spent on premiums that is capped by the program.

  Right Click > Open Image in New Tab to see the full 2020 Federal Poverty Levels Chart

The new state subsidies will benefit qualifying Californians with MAGI Modified Adjusted Gross Incomes in the following sample ranges

Qualifying Annual Income Ranges for Additional State Financial Help in 2020 

Household Size

Up to 138% of FPL* 

200% - 400% of FPL 

400-600% of FPL 


$0 - $17,237 

$24,980 - $49,960 

$49,960 - $74,940 


$0 - $23,336 

$33,820 - $67,640 

$67,640 - $101,460 


$0 - $29,436 

$42,660 - $85,320 

$85,320 - $127,980 


$0 - $35,535 

$51,500 - $103,00 

$103,000 - $154,500 

Average CoveredCA

Additional Subsidies



*Consumers in this income range may also qualify for Medi-Cal.


To see if you qualify for 2020 Subsidies go to > https://apply.coveredca.com/lw-shopandcompare/


In Santa Barbara County, Blue Shield and coming back into the market Anthem Blue Cross will be offering their Individual Plans. 

Medical Providers within 30 mile radius of 93117

Anthem Blue Cross EPO Plans has 941 

Blue Shield PPO Plans has 389


Starting in 2020, California now Mandates everyone to have a Qualified Health Plan or pay a State Tax Penalty.  Penalty is greater of $695 per adult ($347 per child) or 2.5% of annual household income.

For more information about Individual and Employer Tax Credits go to:

 ACA Affordable Care Acts Employer and Employee Information

Contact me if you have questions about any affordable Individual and Group Plans or to obtain a Quick Quote from my Website here at www.jiainsuranceservices.com



James I. Aoki

 Insurance Brokerage Services

Independent Insurance Broker 39 years

   805 962-2277 Office    805 962-9928 Fax

Email:  jim@jiainsuranceservices.com