15 min readNov 3, 2021

Health Insurance 2022 — useful information, benefit designs, income limits, penalty, etc.

Health insurance could be overwhelming to understand, but getting the fundamentals will help you understand it and save money every month on premiums!
As an insurance agent, I’ve helped thousands of individuals, families and small businesses in California understand how their insurance works. Below are some of the frequently asked questions with answers:

Do I need health insurance?

Health insurance provides you and your family affordable access to high-quality health care. Accidents and illnesses can happen without warning, and medical treatments can be expensive. If you do not have health insurance, you will be paying the entire bill yourself. By having health insurance you can shift the financial burden to the insurance company and pay a small fraction of the cost for medical care. Even a high deductible bronze plan can help you cut your medical bill substantially and you will pay only up to the maximum-out-of pocket per year.

What is the penalty if I don’t have health insurance?

As of 2020, individuals and families residing in California are subject to a state tax penalty for not having health insurance unless they qualify for an exemption. To prove that you had health insurance you will need the forms IRS Form 1095-A and FTB 3895. If you need help accessing the forms, please reach out.

What are the dates of 2022 Open Enrollment?

Open Enrollment to enroll in qualified health insurance plans in California runs from November 1, 2021, through January 31, 2022.

If you enroll by December 15, your plan will be effective on Jan. 1, 2022. If you enroll in January of 2022, your plan will be effective on February 1, 2022. Once open enrollment closes, you will not be able to change (upgrade, downgrade) the plans unless you have a qualifying life event (change the address, have a baby, get married, lose your employer-sponsored health insurance or Cobra). You will be allowed to update the income, change the address, etc.

Can my health insurance application be denied?

Under the Affordable Care Act, your application for health insurance is accepted and approved with no pre-existing conditions or waiting periods and can no longer be denied based on your health history. As long as you apply during the open enrollment or during a special enrollment if you have a qualifying life event, your application for health insurance will be approved.

What is a pre-existing condition?

Any health condition or illness that you had before your insurance coverage begins can be considered a pre-existing condition. Pre-existing conditions are covered on all Affordable Care Act-compliant plans, which includes all metal tiers (bronze, silver, gold, and platinum and minimum coverage plans). However short-term medical plans are not ACA compliant and still subject to pre-existing condition exclusions.

Can a health insurance company terminate my individual health insurance policy?

An insurance company can only terminate your policy if you fail to pay your premium within the allowed grace period. By law, you have 30 days to pay your premium. If you fail to pay the premium, your policy will be terminated for non-payment and will not be reinstated until the next open enrollment. You will not be able to enroll in health insurance if the open enrollment closed unless you qualify for special enrollment. If you applied for your plan through the marketplace and fail to submit any requested documents with 90 days, you will lose your eligibility for the subsidy. Your plan will not be canceled, but you will have to pay the full amount of your plan costs without any subsidy assistance.

What is the income limit to qualify for a subsidy/advance premium tax credit via CoveredCA?

You may be eligible for federal assistance when you buy a health plan through your state’s marketplace. This assistance could lower the premiums you pay and reduce how much money you must pay out of your own pocket when you seek medical care. You qualify for assistance based on income. The chart below outlines income limits to qualify for CoveredCa, Medi-Cal, Enhanced Silver 94, Enhanced Silver 87, Enhanced Silver 73 plans based on income.

Reading the chart is easy, just look at the household size and check what you and your children qualify for based on income. If you need help navigating this chart, please feel free to reach out to us and we can help.

What is the California Premium Credit?

Beginning with the year 2022, a new credit of $1.00 per member per month will be applied to qualified health plan (QHP) premiums. This new credit is called the California Premium Credit and is paid directly to qualified health plans. The credit will be paid for consumers enrolled in subsidized, unsubsidized, and catastrophic plans. No credit will be paid for consumers enrolled in dental plans.

How will the federal and state government pay for all the subsidies? Who is funding the money and how long can this be sustained?

Currently, the American Rescue Plan is scheduled to sunset at the end of 2022, however, Congress is currently considering a $3.5 trillion budget reconciliation package. Healthcare priorities in the budget reconciliation package include permanency of ARP subsidies, expanding Medicaid coverage to all states, and bolstering Medicare to cover vision, dental, and hearing.

If you’re unsure if you qualify for assistance with your health insurance costs, you can get a free professional assessment from one of our knowledgeable health insurance agents or use our online quoting tool to find out if you qualify for cost savings and find a plan that works for your budget.

Do I qualify for special enrollment if I voluntarily end COBRA (Consolidated Omnibus Budget Reconciliation Act) because ARP subsidies are going away?

Generally, an individual who elects to enroll in COBRA or COBRA continuation coverage after losing their employer-sponsored insurance (ESI) will not qualify for a Special Enrollment Period (SEP) to enroll in a qualified health plan until their COBRA continuation coverage is exhausted.

An individual is considered to have exhausted their COBRA continuation coverage if the employer completely ceases its contributions or the government completely ceases its COBRA subsidies. A SEP is triggered when a qualified individual or his or her dependent is enrolled in COBRA or COBRA continuation coverage for which an employer or government is paying all or part of the premiums or a government entity is providing subsidies, and the employer completely stops its contributions or government subsidies completely cease.

This triggering event would occur as of the last day of the period for which COBRA is paid for, in part or in full, by an employer or government. The American Rescue Plan’s subsidies for COBRA premiums ended on September 30th, 2021.

Consumers enrolled in a COBRA plan may cancel their COBRA plan and enroll in a Covered California plan during Open Enrollment. In addition, consumers who are offered COBRA may opt-out of initial enrollment in COBRA and apply for a subsidized Covered California plan.

Is Medi-Cal, Medicaid, Medicare, and CoveredCA the same thing?

No, Medi-Cal is a government program in California that allows someone to be eligible based on the current household income. In other states, this is known as Medicaid.

Medicare is not the same as Medi-Cal or Medicaid.

Medicare is the federal health insurance program for:

People who are 65 or older
Certain younger people with disabilities
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

CoveredCa is a platform in California where people can shop and apply for private insurance plans, but pay less if they qualify for a subsidy. People can apply for Medi-Cal on this platform as well.

How does Medi-Cal determine the household income, and what situations would lead to an individual over 138% FPL being determined eligible for Medi-Cal instead of Covered California?

Medi-Cal eligibility is based on the current household monthly income. Children may be eligible for Medi-Cal with household income up to 266% FPL.

Pregnant women may be eligible for enrollment in the Medi-Cal with income up to 213% FPL and eligible for Medi-Cal Access Program (MCAP) with income more than 213% FPL and up to 322% FPL.

Children in San Mateo, Santa Clara, and San Francisco counties may be eligible for the County Children’s Health Initiative Program (CCHIP) which is managed by Medi-Cal.

A fluctuating income can result in a Medi-Cal eligibility determination if the individual initially projects an annual income over 138% FPL and later reports a sudden decrease in income.

It’s also possible for an individual to project an annual income over 138% FPL but not be electronically verified as having such a high income, which would lead to an income inconsistency and a request that the individual prove their income.

Check the table Program Eligibility by Federal Poverty Level for 2022 to see if you qualify for any of these plans/programs based on household income.

What is considered a Mixed household?

CoveredCa refers to families as a mixed household if the parents are enrolled in a private health insurance plan with subsidies and children are enrolled in Medi-Cal under the same case.

For example, for a family of 4 residing in San Francisco, and their household income is $53,000/year, then parents will be enrolled in a subsidized health plan via CoveredCa and children will be enrolled in Medi-Cal. This is considered a mixed household. If the income for this household changes, parents should report the income directly to Medi-Cal.

Family of 4 residing in San Francisco. Income is $53,000/year Parents qualify for subsidized/enhanced silver plans via CoveredCA and children qualify for Medi-Cal

Get a quote online and compare your 2022 health insurance options.

Will mixed households with children on Medi-Cal and parents on Covered California still be able to make changes or will that still require the parents to make those changes through the County?

Changes for mixed households are made through the County (Mei-Cal office). Covered California can process name changes for the members in a Covered California plan only; members who report changes themselves on CoveredCa.com should call their county within 5 business days to confirm that their changes were received.

What is the best health insurance plan- bronze, silver, gold, or platinum?

This is a million-dollar question! What is best for me is not necessarily the best health insurance plan for you! I always ask people to compare their options before buying a health insurance plan. Remember, the age, zip code and household income determine how much you pay for your health insurance. Shop and compare before you enroll! You can run a comparison on the official website: www.CoveredCa.com or reach out to us and we can help with the quote.

We can send you a side-by-side comparison of all the plans, which will make it easy for you to make the decision and select the best health insurance plan for you and your family!

The table below outlines the basic benefits of health plans offered in 2022.

What is the best PPO or HMO?

When you’re shopping for health insurance, you have a lot of options to choose from. All these insurance companies like Blue Shield, Kaiser, HealthNet, Anthem BlueCross, Oscar, and so on… offer both PPOs and HMOs. But there are other less-known options like EPO’s and POS.

Knowing the differences between these plans can help you choose the one that’s right for your health care needs and budget. A PPO is not necessarily better than an HMO. Other things are also important to consider when you are shopping for a health insurance plan for you and your family. You have to pay attention to such things as deductible, co-insurance, co-pays, and out-of-pocket maximum. While the PPO and HMO describe the general types of access to the care you have available to you, you will have to look beyond and understand other conditions of your medical plan. I have videos where I talk about deductibles, and compare various health plans so if you have a minute, feel free to learn more by watching my videos available for free on YouTube.

The table below outlines basic differences between HMOs, PPO’s, EPO’s and POS plans. You can also read the detailed article on my blog on this topic.

What health insurance companies can I choose from?

The health insurance companies available in California for individuals and families include Blue Shield, Kaiser, HealthNet, Anthem BlueCross, Oscar, VHP, Sutter Health, Western Health Advantage, etc. Some of these companies are offered in the CoveredCa. We will quote other insurance companies as well. Feel free to reach out and we can discuss what would work best for your and your family.

What is a health savings account?

A health savings account is tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a High Deductible Health Plan (HDHP). The funds contributed to the account are not subject to federal income tax at the time of deposit. Funds may be used to pay for qualified medical expenses at any time without federal tax liability. Withdrawals for non-medical expenses are treated very similarly to those in an IRA account in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier.

What are the HSA contribution limits for 2022?

To qualify for a health savings account in 2022 one must be enrolled in a High Deductible Health Plan with a minimum deductible of $1,400 for single coverage and $2,800 deductible for family coverage.

You can contribute up to $3,650 in 2022 if you have self-only coverage or up to $7,300 for family coverage.

Note: If you are age 55 or older, you can make an additional $1,000 catch-up contribution.

Who is eligible for Covered California subsidy?

Anyone who has a valid immigration status and qualifies based on income (and pays taxes!) is eligible for advance premium tax credits or a subsidy. This subsidy reduces your monthly premium and you pay as low as $0/month for a private health insurance plan. You can apply via CoveredCa even if your income is higher, but you will be paying more for your health insurance.

Household income, age, and zip code primarily determine if you qualify for a subsidy. It is important to correctly estimate your income for the year you are requesting coverage in order to avoid mistakes with the subsidy.

What dental plans are available on the market?

There are a variety of dental insurance plans available on the market. You can apply for dental insurance year-round, but if you would like to add negotiated dental insurance in the CoveredCA — you will have to do it during the open enrollment. CoveredCa dental plans have shorter waiting periods.

Typically dental insurance has 3, 6, or 12 months waiting periods for basic and major benefits.

HERE IS THE TYPICAL BREAKDOWN OF DENTAL BENEFIT CATEGORIES.

· Major– is Usually covered at 50%- Which means the insured (patient) pays the other 50%- Most of the time crowns, bridges, dentures, partials, inlays, onlays, etc are considered major. (PPO plans have 6–12 months waiting period before benefits begin)

· Basic– Usually covered at 80%- Which means the insured (patient) pays the other 20%- Most of the time fillings, extractions, periodontal services, root canals, core build up, quadrant scaling, scaling and root planing, etc are considered basic. (PPO plans have 3–6 months waiting period before benefits begin)

· Preventative– Usually covered at 100%- Which means the insured (patient) pays nothing additional- Most of the time routine cleanings, x-rays, exams, dental sealants etc are considered preventative. There are usually timing limitations to the cleanings and sealants, these are different on almost every policy.

What types of vision insurance are available?

One of the most popular vision insurance plan in California is VSP. You can buy a vision plan year-round with benefits available as soon as the following day. Enrollment is easy and you can enroll online in less than 5 minutes. Here is the link to the CoveredCa negotiated rates with VSP: https://www.vspdirect.com/4ca?utm_source=covered_california_broker&utm_medium=referral&utm_content=VSPCA00326&utm_campaign=exchange

How can I get help with my CoveredCa account?

You can reach out to the CoveredCa Customer Service 1–800–300–1506 or you can reach out to us! . As a Certified Insurance Agency, we can also help with your CoveredCa. Feel free to delegate us from your account dashboard and we will assist with any issues you might have including eligibility, changing or updating the information, appeals, retrieving tax forms 1095-A and FTB 3895, providing proof of coverage forms, etc.

Here is how you can delegate us so we can assist with your existing CoveredCa account:

1. Go to www.CoveredCA.com web page

2. Log in with your username and password

3. Go to “Need Help” tab (the upper right corner) — select “Find Local Help”

4. Select “Find an Agent” or “Agents”

5. Search by name: Type in: Diana Polyakov -

6. You will be asked to agree to the disclosures

7. Please sign your/her name and click continue or agree.

8. From that point, we will be able to verify the application for completeness or errors, submit additional information on your behalf, etc.

Here is the step-by-step instructions on the agent delegation. https://insurancecenterhelpline.com/our-blog/f/how-to-designate-a-certified-insurance-agent-in-coveredca

Is there an extra fee to use an insurance agent or broker?

No, health insurance agents and brokers are paid a commission by the health insurance company. Your insurance rates will always be the same whether you use an agent or buy directly from an insurance company. For no additional charge, an insurance agent can provide advice and assistance during the insurance application process.

I hope this information was helpful for you! If you have an issue with your CoveredCa account or have a specific question, please feel free to reach out directly or you can delegate me as your agent and I’ll do my best and help you solve the issues. I am a CoveredCA Certified Insurance Agent and I am familiar with most issues and have successfully helped many consumers in the past!

We love helping people! We are an independent insurance agency in California helping individuals, families and small businesses find affordable health insurance plans that would work best for them and allow them to save money!

Feel free to reach out if you have questions or need help with finding the best health insurance plan and compare it with other companies!

Frequently Asked Questions:

Health Insurance Open Enrollment 2022

What is the income limit to qualify for Obamacare health insurance in 2022?

HMO vs PPO which one is best?

What is the income limit to get a subsidy in CoveredCA?

Can I get a health insurance stipend if I drive for Uber, Doordash and other apps?

Where can I get IRS form 1095-A and FTB 3895?

Dental Insurance PPO or HMO?

Cobra health insurance or CoveredCA?

When is the open enrollment to get health insurance for 2021?

What is Covered by Dental Insurance?