Individual & Family Health Insurance in California

Plan Design

ACA metal tiers: Bronze, Silver, Gold, Platinum

All ACA plans cover the same essential health benefits. The tiers just change how costs are split between your monthly premium and the out-of-pocket costs you pay when you use care.

Bronze

Lowest monthly premium. Highest cost-sharing when you use care (deductibles, copays). Best for healthy people who rarely use care and want to minimize monthly costs.

Actuarial value: ~60%

Silver

Middle ground on premium and cost-sharing. Only tier eligible for Cost-Sharing Reductions (CSR) if your income qualifies. Silver 73/87/94 plans can offer significantly better coverage at a low or zero premium.

Actuarial value: 70% (+ CSR up to 94%)

Gold

Higher monthly premium, lower out-of-pocket costs. Good choice if you use care regularly (prescriptions, specialist visits) and want predictable costs.

Actuarial value: ~80%

Platinum

Highest monthly premium, lowest cost-sharing. Ideal if you have significant ongoing health needs and want maximum coverage when you use care.

Actuarial value: ~90%

Actuarial value is the percentage of total covered health care costs the plan pays on average across all enrollees. A Bronze plan at 60% means the plan covers 60% and you cover 40% on average — but your personal experience will vary depending on what care you actually use.

Financial Help

Advanced Premium Tax Credits (APTC)

The APTC is a federal tax credit that lowers your monthly health insurance premium. It's available to households with incomes between 100% and 400% of the Federal Poverty Level (FPL) who enroll through Covered California.

Instead of waiting until you file taxes, most people receive the credit in advance — Covered California sends it directly to your insurance company each month, and you pay only the difference.

How the amount is calculated: Your subsidy equals the cost of the second-lowest-cost Silver plan in your area (the "benchmark plan") minus your expected contribution, which is a percentage of your income set by federal law. The lower your income, the smaller your expected contribution, and the larger your subsidy.

"A $249/month subsidy on auto-pilot: the APTC is paid directly to your insurer each month. You only see the net bill."

Important 2026 change: The enhanced federal subsidies from the American Rescue Plan and Inflation Reduction Act expired December 31, 2025. The 8.5% income cap and above-400%-FPL assistance are no longer available. Premiums for middle-income households increased significantly in 2026. California does maintain a limited state subsidy for households up to 165% FPL. Report income changes to Covered California promptly — if your income ends up higher than estimated, you may owe back some or all of your APTC at tax time, with no repayment cap for higher earners.

Example: APTC in action

A single person earns $36,000/year (about 230% FPL). The benchmark Silver plan in their county costs $480/month. Federal rules say they should contribute about 7.7% of income — roughly $231/month. Their APTC is $249/month, paid automatically to the insurer. They see a $231 bill.

If they choose a cheaper Bronze plan at $310/month, they pay only $61/month. If they choose Gold at $600/month, they pay $351/month. The subsidy amount stays the same regardless of which plan tier you pick.

Extra Help

Cost-Sharing Reductions (CSR)

If your income is between 138% and 250% FPL, you may also qualify for Cost-Sharing Reductions — a separate benefit that lowers the deductible, copays, and out-of-pocket maximum on Silver plans.

CSR is only available on Silver plans, and only through Covered California. To get it, you must choose a Silver plan — you can't apply CSR to a Bronze, Gold, or Platinum plan even if you qualify.

Silver 94

Income 100%–150% FPL. Plan pays about 94% of costs. Deductibles and copays are dramatically reduced. The single most valuable plan option for eligible households.

Silver 87

Income 150%–200% FPL. Plan pays about 87% of costs. Still a significant upgrade over a standard Silver plan's 70% actuarial value.

Silver 73

Income 200%–250% FPL. Plan pays about 73% of costs. A modest improvement over standard Silver, but still worth selecting over other tiers at this income level.

Household Size	100% FPL	138% FPL Medi-Cal cutoff	150% FPL Silver 94 cutoff	200% FPL Silver 87 cutoff	250% FPL Silver 73 cutoff	400% FPL APTC cutoff
1 person	$15,650	$22,025	$23,475	$31,300	$39,125	$62,600
2 people	$21,150	$29,864	$31,725	$42,300	$52,875	$84,600
3 people	$26,650	$37,702	$39,975	$53,300	$66,625	$106,600
4 people	$32,150	$45,540	$48,225	$64,300	$80,375	$128,600
5 people	$37,650	$53,379	$56,475	$75,300	$94,125	$150,600
6 people	$43,150	$61,217	$64,725	$86,300	$107,875	$172,600
Each add'l	+$5,500	+$7,839	+$8,250	+$11,000	+$13,750	+$22,000

Coverage Standard

Minimum Essential Coverage (MEC)

Minimum Essential Coverage (MEC) is the baseline standard for what counts as real health insurance under the ACA. Having MEC means you won't face a federal tax penalty (California also has its own individual mandate penalty for lacking MEC).

What counts as MEC:

Employer-sponsored health insurance
Plans purchased through Covered California
ACA-compliant individual plans purchased off-exchange
Medi-Cal (full-scope)
Medicare Parts A and B
TRICARE, VA coverage, CHIP

What does NOT count as MEC:

Short-term health plans (limited duration)
Accident-only plans
Dental or vision-only plans
Fixed-indemnity health plans
Health care sharing ministries

California imposes a state individual mandate. Going without MEC for more than three months in a year may result in a penalty when you file your California state tax return. The penalty can equal 2.5% of household income above the filing threshold, or a flat dollar amount per uninsured household member — whichever is higher.

Know What You're Getting

What individual & family plans cover — and what they don't

All ACA-compliant individual plans must cover 10 categories of essential health benefits. But there are also important gaps — and some nuances that catch people off guard.

The 10 Essential Health Benefits every ACA plan must cover

Ambulatory (outpatient) services — doctor visits, urgent care, same-day procedures that don't require a hospital admission.
Emergency services — ER care, including out-of-network ERs during a true emergency (plans can't charge more for out-of-network ER visits in a genuine emergency).
Hospitalization — inpatient hospital stays, surgery, nursing care, and services received while admitted.
Maternity & newborn care — prenatal visits, labor and delivery, and care for the newborn. This was not required before the ACA, and many pre-ACA plans excluded it entirely.
Mental health & substance use disorder services — outpatient therapy, inpatient psychiatric care, counseling, and substance use disorder treatment. Coverage must be equivalent in strength to physical health coverage ("mental health parity").

Prescription drugs — plans must cover at least one drug in each category and class. Specific formularies (which drugs are covered) vary by plan.
Rehabilitative & habilitative services — physical therapy, occupational therapy, speech therapy, and devices that help with recovery or daily functioning.
Laboratory services — blood tests, urinalysis, diagnostic imaging, and other lab work ordered by your doctor.
Preventive & wellness services — annual physicals, immunizations, cancer screenings, well-woman visits, and other preventive care — at no cost-sharing when provided in-network.
Pediatric services — health care for children including dental and vision coverage. Note: adult dental and adult vision are not required EHBs, though some plans include them voluntarily.

Important coverage gaps — what individual plans often don't cover

Things individual plans may not cover

IVF and advanced fertility treatments — California's new SB 729 law requires IVF coverage only for fully insured large-group employer plans (101+ employees). Individual market plans are specifically excluded — IVF is generally not a required benefit on Covered California or off-exchange individual plans. Infertility diagnosis and artificial insemination may be partially covered under some plans.
Adult dental care — routine dental care for adults (cleanings, fillings, crowns, extractions, root canals, implants) is not an ACA essential health benefit for adults. Pediatric dental is required, but adult dental is optional. Some plans offer it as a rider or separate add-on.
Adult vision care — routine vision exams and corrective lenses for adults are not required EHBs. Pediatric vision is required. Adults can purchase a standalone vision plan separately.
Long-term care — extended nursing home stays, assisted living, and ongoing custodial home care are not covered. Short-term skilled nursing care after a qualifying hospital stay may be covered, but long-term care requires separate long-term care insurance or Medi-Cal.
Cosmetic procedures — surgery, injections, or other procedures done solely for cosmetic purposes. Reconstructive surgery following an accident, illness, or mastectomy is typically covered.
Weight loss surgery nuances — bariatric surgery (gastric bypass, sleeve gastrectomy) coverage varies significantly by plan. Some plans cover it with prior authorization; others exclude it entirely. Always verify before assuming it's covered.
Non-emergency medical transport — rides to scheduled appointments (e.g., dialysis, chemotherapy) are not typically covered. Emergency ambulance is covered; routine medical transport generally is not.
Alternative & complementary medicine — acupuncture, naturopathy, homeopathy, and massage therapy for general wellness are not required EHBs, though some plans voluntarily cover limited sessions (e.g., chiropractic or acupuncture).
Out-of-network care — HMO plans don't cover out-of-network care (except emergencies). EPO plans also exclude out-of-network. PPO and POS plans cover out-of-network but at a significantly higher cost-sharing rate. Always check the network before scheduling a specialist.
Experimental or investigational treatments — treatments not yet approved or considered "investigational" by the insurer may be denied. Clinical trial participation rules vary by plan; ACA plans must cover routine care costs for approved clinical trials.

Important protections ACA plans must provide

No lifetime or annual dollar limits on essential health benefits — your insurer cannot cap how much they'll pay for covered care over your lifetime.
No pre-existing condition exclusions — plans cannot deny you coverage or charge you more because of a health condition you had before enrolling.
Annual out-of-pocket maximum ($10,600/individual and $21,200/family in 2026) — once you hit this limit, the plan pays 100% of covered in-network services for the rest of the year.
Dependent coverage to age 26 — you can keep children on your plan up to their 26th birthday, regardless of whether they live with you, are students, or are married.
Free contraceptive coverage — FDA-approved contraceptives must be covered with no cost-sharing for women. This includes the full range of contraceptive methods under HRSA guidelines.
Mental health parity — coverage for mental health and substance use disorder treatment must be equal in strength to coverage for medical and surgical care.

California note: California's benchmark plan and state law add some additional required benefits beyond the federal floor — including some fertility diagnosis coverage, domestic partner coverage, and certain cancer screenings. Coverage details vary by carrier and plan, so always read the Summary of Benefits and Coverage (SBC) before enrolling.

Low-Income Coverage

Medi-Cal: California's Medicaid program

Medi-Cal provides free or very low-cost health coverage to millions of Californians. If your household income is at or below 138% of the FPL, you'll typically be directed to Medi-Cal rather than a Covered California subsidy plan.

What Medi-Cal covers

Doctor visits and preventive care
Hospital and emergency care
Prescription drugs
Mental health and substance use services
Dental and vision care
Long-term care (nursing home and in-home supportive services) — for eligible adults

Who qualifies (adults)

Adults 19–64 with income at or below 138% FPL (MAGI Medi-Cal) — no asset test
Adults 65+ or with disabilities: income and asset limits apply (see Medicare section for dual-eligible details)
Pregnant individuals up to 213% FPL
Children up to 266% FPL
Must be California residents and U.S. citizens, permanent residents, or certain other immigration categories

Medi-Cal and Covered California eligibility are determined at the same place — when you apply through Covered California, you'll be automatically screened for Medi-Cal as well. If you qualify for Medi-Cal, you'll be enrolled in a Medi-Cal managed care plan at no cost, rather than a Covered California subsidized plan. Apply at CoveredCA.com →

Individual & family health insurance in California

California's individual market: your main options

Covered California (ACA Marketplace)

Off-Exchange Private Plans

Medi-Cal