OBAMA CARE
Covered California is the state’s official health insurance marketplace, designed to help individuals, families, and small businesses access quality coverage at affordable rates.
Health insurance helps protect you from high medical costs and gives you access to medical care when you need it. Whether you're shopping for an Individual & Family Plan, a Medicare plan, or employer coverage, the core basics of how health insurance functions remain the same. Understanding these fundamentals makes it easier to compare plans and choose the coverage that fits your needs and budget.
Must Know Terms
Monthly Premium
Your premium is the amount you pay each month to keep your health insurance active.
- Premiums do not count toward your deductible or out-of-pocket maximum.
- Plans with lower premiums usually have higher deductibles, and vice-versa.
Cost Sharing
In addition to your premium, most plans require cost sharing when you receive care.
Deductible
The amount you must pay out of pocket before your plan starts paying for most services.
Preventive care is exempt and always covered at $0.
Copay
A fixed dollar amount you pay for services, such as $35 for a doctor visit or $10 for a generic prescription.
Coinsurance
A percentage you pay for services after meeting the deductible.
For example, you might pay 20% of the cost of an X-ray while your plan pays 80%.
Out-of-Pocket Maximum (OOP Max)
This is the most you will pay for covered services in a calendar year. Once you reach your OOP Max:
- Your plan pays 100% of covered in-network services for the rest of the year.
- Deductibles, copays, and coinsurance all count toward this limit.
Find plans and pricing in minutes
Compare options through the official Covered California marketplace. Prefer help? Call us and we’ll walk you through it.
You will be redirected to the official Covered California website to view plan options and complete enrollment.
Understanding Provider Networks
Health insurance companies contract with medical providers—such as doctors, specialists, hospitals, labs, and clinics. These contracted providers make up your network.
In-Network Care
- Lower, predictable costs
- No balance billing
- Covered at the plan’s standard copay or coinsurance
Out-of-Network Care
Costs are much higher and depend on your type of plan.
HMO Plans
- No out-of-network coverage (except true emergencies)
- You must use in-network doctors
- Requires a Primary Care Physician (PCP) and referrals
PPO Plans
- Covers both in-network and out-of-network care
- Out-of-network costs have higher deductibles and higher coinsurance
- Separate out-of-pocket maximums may apply
- No referrals required
Using in-network care whenever possible helps keep your expenses low and avoids unexpected medical bills.
Preventive Care
All ACA-compliant plans cover preventive care at $0 cost, including:
- Annual physicals
- Vaccines
- Screenings (such as mammograms and colonoscopies)
- Well-baby and well-child visits
Preventive services are covered even if you have not met your deductible.
Summary
Health insurance works by sharing the financial risk between you and your insurance company. You pay a monthly premium to stay covered, and when you receive care, you share part of the cost through deductibles, copays, or coinsurance. Staying in-network and understanding your plan’s structure helps you get the most value while keeping your medical costs predictable.
LEARN MORE
CA HEALTH EXCHANGE
Covered California serves as the state’s trusted health insurance marketplace, connecting individuals, families, and small businesses with reliable, low-cost coverage options.
INCOME GUIDELINES
Explore California’s Obamacare income guidelines to find out whether you’re eligible for premium assistance or other government savings.
ONLINE SERVICES
Discover how simple it is to get covered through the Covered California. Login, compare plans, apply for coverage, and more.