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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.  Individuals are subject to the Individual Shared Responsibility Provisions of the ACA also known as the ACA Individual Mandate.  Those who do not comply with the ACA Mandate will pay a Penalty Fee. This requires All Individuals to have a Qualified Compliant Health Plan. If an Individual decides not to purchase an ACA Plan, then they will be subject to the ACA’s Individual Shared Responsibility Provisions and pay a 2 ½% Penalty Fee based on their Household Modified Adjusted Gross Income. 

 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 2019 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?


OPEN MARKET = 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  




?             New 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


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 400 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.


Qualifying for Tax Credits and Cost-sharing Subsidies

2019 Household Income Guidelines with INDIVIDUAL PLANS

for Medi-CAL, Tax Credit and Cost Sharing Subsidies

The ACA Individual Mandate requires All Individuals to have a Qualified Compliant Health Plan.   To see if you qualify for Federal Financial Assistance depends on your household income and family size. You will have to estimate your incomes for the year.  Your W2 monthly income times 12 months should be helpful.  More specifically it will be based on your Modified Adjusted Gross Income.  See the charts below to help determine if you qualify for financial help in 2019 for your INDIVIDUAL PLAN. 

Program Eligibility by Federal Poverty Level (FPL) for 2019 OEP for Coverage Effective after 1/1/19

Household Size

Cost Sharing Reduction

Eligible for Income-Based Medi-Cal

Eligible for Premium Assistance (PA) (=100% to =400%)


Medi-Cal Access Program (No PA)
formerly AIM (Access for Infants & Mothers) 
(> 213% to = 322%)


Silver Cost Sharing Reductions (CSR)


(=100 to =150% FPL)

(>150 to =200% FPL)

(>200 to =250% FPL)



MAGI Medi-Cal (kids 0-18 yrs.) up to 266% FPL




= 138%

> 138%



> 213%


= 266%


= 322%


































































































For each additional person, add












* Cost Sharing Subsidy is an upgrade in benefit plan to the Silver Tier for lower income households.

 The amount of the Tax Credit Subsidy for an INDIVIDUAL PLAN is based on the following:

  1. Household Size
  2. Household Total Income
  3. Household Ages

 For the Estimated Tax Credit Rate Calculator towards Plans Premiums go to  https://apply.coveredca.com/lw-shopandcompare/ 


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

 ACA Affordable Care Acts Employer and Employee Information

 Overview of Health Care Reform's ACA Affordable Care Act 


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 Services

Independent Insurance Broker 38 years

   805 962-2277 Office    805 962-9928 Fax

Email:  jim@jiainsuranceservices.com