The Affordable Care Act survived a series of efforts this year to repeal the health care law signed by former President Barack Obama in 2010.
As people consider their options for coverage in 2018, those who are eligible can still use tax credits that lower the premiums of health insurance plans available on the Covered California exchange.
The current enrollment period for 2018 coverage runs through Jan. 31; the deadline is Dec. 15 for coverage effective Jan. 1.
Covered California made adjustments to preserve the cost-sharing subsidies that reduce co-pays and other out-of-pocket expenses for many residents, even though President Trump cut off funding for those benefits. Residents with income between 139 percent and 250 percent of poverty level are eligible for cost-sharing subsidies that remain in effect next year.
One development affects a large number of consumers who buy insurance on the independent market in Covered California's pricing region that includes Stanislaus, San Joaquin, Merced, Mariposa and Tulare counties.
While Anthem Blue Cross decided to withdraw from most of California's individual market, it continues to serve the Central Valley pricing region. According to Covered California, which serves 67,000 people in the five-county region, Anthem customers made up more than 65 percent of those consumers this year.
For 2018, Anthem will replace its preferred provider plan or PPO with a significantly different type of plan called an exclusive provider plan or EPO.
Debra Wright of Wright Insurance Agency of Modesto said Covered California will move affected customers into the Anthem EPO if they don't change their insurance for 2018. Anthem will make the change for its customers who buy the coverage off the exchange.
Wright said the provider network for the EPO is about the same as the PPO, but customers need to understand the terms of the EPO. It does not cover medical bills for patients who use services outside the provider network, except in a medical emergency.
"They have to make sure the physicians they see are contracted with the network," Wright said. "If they go outside the network, they are a cash patient."
Premiums are expected to increase an average 24 percent in the Central Valley region, mostly because Anthem announced sharp rate hikes for 2018. Kaiser Permanente, Blue Shield and Health Net also compete for local customers who use the exchange. Anthem was required to scale back the increases and, according to experts, rate hikes have little effect on the premiums for people entitled to subsidies. Their tax credits increase as the rates go up, so they won't be hit by significant increases.
About half of the 1.4 million participants in Covered California statewide have the Silver plans with cost-sharing benefits that lower their out-of-pocket expenses. Those benefits are available for individuals who earn less than $30,000 a year or families of four with income below $61,500 a year.
Leaders at Covered California preserved the cost-sharing program by adding a 12 percent surcharge to Silver plans to compensate insurers who are required by the ACA to provide the benefits. Because tax credits are pegged to premiums, a large majority of households with cost-sharing benefits won't see a premium increase tied to the surcharge and some will see a modest increase.
Premium increases will be a shock for people who earn too much to qualify for subsidies -- they represent 7 percent of Covered California customers in the Central Valley region. Those adults including the self-employed and early retirees are exposed to the steep costs for insurance on the individual market.
A Modesto couple, both 60 years old, with income of $66,000 a year, will pay $1,817 a month for a Kaiser Silver HMO next year, according to Covered California's "shop and compare" tool. The plan has a $5,000 deductible, but patients can use services such as doctors visits before meeting the deductible.
An Anthem Blue Cross Silver EPO with a $5,000 deductible is priced at $2,182 a month for the same couple and a Blue Shield Silver PPO will cost them $2,428 a month.
Sutter Health Plus is an option off the exchange for Stanislaus and San Joaquin county residents without premium assistance. Wright said the rates for the Sutter HMO coverage are competitive with Kaiser. Enrollees don't have access to the full Sutter network "but so far it has worked well with my clients who want to keep their physicians at Sutter," Wright said.
For a 40-year-old individual, Sutter Health Plus will cost $436 a month. A 50-year-old will pay $610 a month and the plan will cost $927 per month for a 60-year-old.
Wright said she advises customers to buy insurance off the exchange if they're not eligible for the ACA subsidies. "You have to watch your income very closely if you are getting a tax credit," Wright said. "I have clients (who were with Covered California) who had to pay back thousands of dollars because they did not report their income properly."