California health insurance - Covered California Questions - difference between in and out of Exchange health plans

What's The Difference Between In And Out Of Exchange Health Plans?

Q: What is the difference between in-exchange and out-of-exchange health plans in California?

In-exchange plans are sold through Covered California and allow eligible enrollees to receive premium subsidies based on their income; out-of-exchange plans are sold directly through carriers or brokers and do not qualify for subsidies. The underlying plan designs and benefits are often similar or identical between the two markets. If subsidies are a factor for you, an in-exchange plan is generally the only path to financial assistance.

Q: Can I get a subsidy if I buy a health plan outside of Covered California?

No — premium tax credits (subsidies) are only available through Covered California, the state's official exchange. If you purchase a plan directly from a carrier or broker outside the exchange, you are not eligible for subsidy assistance regardless of your income. Use a Covered California quote to see whether you may qualify for financial help.

Q: Are the plans inside and outside Covered California from the same insurance carriers?

In many cases, yes — major California carriers participate in both the exchange and the off-exchange market, and some plans may be identical or very similar in benefits and network. However, not every carrier or plan available off-exchange is also available on-exchange, so it pays to compare both markets. A licensed agent can help you identify which options apply to your situation.

Q: Why would someone choose an off-exchange health plan over a Covered California plan?

The primary reason to go off-exchange is if you do not qualify for subsidies and prefer a plan or carrier that may not be available through Covered California. Some people also choose off-exchange plans if their income or household situation makes subsidy eligibility unlikely. That said, it's worth comparing both markets before deciding, since carrier and plan availability can vary.

Q: Is it free to get help comparing in-exchange and out-of-exchange plans in California?

Yes — working with a licensed California agent like those at CalHealth.net costs you nothing; you pay the same premium as going directly to the carrier. Agents can compare both Covered California and off-exchange options side by side to help you find the right fit. CalHealth.net (Goodacre Insurance Services, licensed since 1994) serves consumers statewide across all California regions.

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This is a great question and we're still getting answers on a daily basis as the actual roll-out of the ACA law occurs.

Let's look at the core differences (few) and similarities (many) and potential advantages either way.

First, we need a lay of the land.

You can always run your quote here:

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Quick Summary of Exchange and non-Exchange Marketplaces

California health insurance benefits comparison chart showing in-network and out-of-network Exchange plan differences

The Exchange is really the new "marketplace" for California health insurance.

You can think of the non-Exchange plans as the existing marketplace although under new rules and requirements.

You're going to see Metallic plans mentioned which refers to the standardized benefit levels (Platinum, Gold, Silver, and Bronze).

If a carrier offers a plan in the Exchange, they must offer that exact plan out of the Exchange.

Let's first talk about what is the same between in and out of Exchange plans.

In and Out of Exchange Plans Similarities

The Plan Benefits for an equivalent metallic plan must be the same both in and out of the Exchange
The rates for equivalent metallic plans must be the same
The networks for equivalent metallic plans must be the same

Essentially, these plans, rates, and networks will be identical between like plans both in and out of the Exchange. So what's different?

Differences between In and Out of Exchange Plans

Availability of health subsidies if eligible are only available in Exchange
Availability of cost sharing benefit if eligible is only available in Exchange
Enrollment process is simpler out of Exchange if not eligible for Subsidy

You can access the online application here:

So what are the primary drivers of going either in or out of the Exchange?

There are large subsidies in Covered California if your income is below a certain range

Number One is the Health Subsidy and Cost Sharing Benefit.

If you qualify for either (AGI income estimate above 138% of the Federal Poverty Level - ask us for most recent income chart or run quote here), you really should get an Exchange plan and we can help you with this more complicated process at no cost to you.

Call 800-320-6269 and find out your CORRECT subsidy amount in 5 minutes

These days, there's not much reason to go off-exchange.

Either way, we can help you evaluate both options especially taking into account Health Subsidies and Cost Sharing Benefits.

There is no cost to our service and having a guide to this process will help ensure that you do not overlook or miss out on the best value.

You can run your Covered Ca Health Plan Quote here to view rates and plans side by side from the major carriers...Free.

Again, there is absolutely no cost to you for our services. Call 800-320-6269 Today!

Frequently Asked Questions

▸ What is the difference between in-exchange and out-of-exchange health plans in California?

▸ Can I get a subsidy if I buy a health plan outside of Covered California?

▸ Are the plans inside and outside Covered California from the same insurance carriers?

▸ Why would someone choose an off-exchange health plan over a Covered California plan?

▸ Is it free to get help comparing in-exchange and out-of-exchange plans in California?

The answers above are general information about California health insurance and may change as rates, plans, and rules are updated each year. They are not a substitute for personalized advice. For current, personalized guidance, please contact us, email help@calhealth.net, or call 800-320-6269. Serving California since 1994.