Covered California Individual and Family Plan Changes for 2016

by Jessica Howland and Stephen Saucier.

2016Every year it’s safe to assume that there will be some changes made to Covered California’s Individual and Family Plan coverage benefits. This year will be no exception. While it doesn’t appear like there will be any major changes, there will be some minor changes that will help consumers make better apples-to-apples comparisons with more plan transparency.

The most significant changes will affect all Bronze 60 and Silver 94 plans along with a maximum monthly out-of-pocket cost on specialty drugs across the board.


Bronze 60 Change Highlights

  • Medical deductible increases to $6,000 for an individual and $12,00 for a family
  • First cumulative three office visits consisting of  specialty care, primary care, mental health or urgent care will not be subject to the deductible
  • Laboratory work – deductible no longer applies
  • After deductible is reached, 100% coverage applies on x-rays, emergency, and hospitalization
  • Maximum Out-of-Pocket increases to $6,500 for an individual and $13,00 for a family


Silver 94 Change Highlights

  • New $75/$150 deductible applies on emergency, hospital services and preferred brand name drugs.


Miscellaneous Changes

  • All metal-tier plans will now have a maximum monthly out-of-pocket cost on specialty drugs (once the pharmacy deductible is reached).
  • Lab benefits have improved on most plans
  • Maximum Out-of-Pocket will no longer be $6,250 for an individual and $12,500 for a family on most plans. It will be graduated:
  • $6,500/$13,000 for Bronze 60 (increased from last year)
    • $6,500/$13,000 for Bronze 60 HSA (increased from last year)
    • $6,250/$12,500 for Silver 70 (unchanged)
    • $5,450/$10,900 for Silver 73 (increased from last year)
    • $2,250/$4,500   for Silver 87 (unchanged)
    • $2,250/$4,500   for Silver 94 (unchanged)
    • $6,200/$12,400 for Gold 80 (decreased from last year)
    • $4,000/$8,000   for Platinum 90 (unchanged)
    • $6,600/$13,200 for Minimum Coverage (unchanged)

Those looking to sign up during open enrollment starting November 1, 2015 or renew their health plan coverage through Covered California starting in October 2015 can expect fewer bumps and clearer plan comparisons which results in better decisions and higher satisfaction which is the ultimate goal.