San Diegans for Healthcare Coverage, A Coalition for Health

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Help Paying for Coverage

The goal of the Affordable Care Act (ACA) is to ensure that everyone legally living in the United States has healthcare coverage. In order to meet that goal, the ACA ensures that there are affordable healthcare coverage options available to people at all income levels.

At a Glance

At a Glance

You can get help paying for coverage in a couple of ways:

  • Premium Assistance through the Exchange
  • No-cost or low-cost Medi-Cal or other public programs

Programs that reduce cost and increase access will be implemented in phases from now through 2014.

This section provides an overview of the following sources of affordable health insurance and premium assistance:

Premium Assistance

Premium Assistance for Health Benefit Exchange Plans

The Affordable Care Act (ACA) creates Health Benefit Exchanges where individuals and families, as well as employers with fewer than 100 employees may purchase insurance. In California, the state will operate the California Health Benefits Exchange for individuals and families, and the Small Business Health Options Program (SHOP) for business. Premium assistance is available to individuals and families through the Exchange to those who can’t afford to pay the full cost of their premiums.

The Premium Assistance available depends upon your income as compared to the Federal Poverty Level (FPL). Your Share of Premium (the maximum that you will have to pay) will be calculated using your income and your family size. If the premium for the Silver benefit plan exceeds your Share of Premium, Federally funded Premium Assistance will be paid to the Health Benefit Exchange to make up the difference. You may use your Premium Assistance to purchase a more comprehensive health plan offered on the Health Benefit Exchange as long as you pay the remaining balance.

Follow these steps using the Table below to determine your FPL category and your maximum monthly premium.

Step 1: Use the “family size” column on the left to locate the row for your family size. Note: Pregnant women count as two people for the purpose of this chart.

Step 2: Follow that row across and locate the column that contains your monthly income.

Step 3: Follow that “monthly income” column downward to the shaded row to determine your FPL % Category.

Step 4: Use the percentage listed directly below your FPL to calculate your maximum monthly premium.

Example Case for Family of Four:

A family of 4 with a monthly income of $2480 falls within the 133-150% FPL category. Therefore, their monthly premium for a Silver benefit package purchased from California’s Health Benefit Exchange cannot exceed $99 ($2480 x 4%). Assuming the lowest Silver premium offered is $1200 per month, this family’s share of the premium will be $99 and the Premium Assistance from the Federal Government will pay $1101 to the Health Benefit Exchange. This family may purchase a more comprehensive plan from the Health Benefit Exchange if they can afford it but the Premium Assistance will not exceed $1101 a month

Note:  Example only. Calculations will vary based on annual updates and final formulas.



Historically, Medi-Cal has not covered all low-income individuals but has required additional eligibility criteria such as being a child, a senior, disabled, pregnant or diagnosed with other conditions, at differing financial eligibility levels depending on the program.  Under health reform, Medi-Cal will be expanded to include all adults under 138% of the federal poverty level who are citizens or legally resident for 5 or more years.  For example, under 2011 FPL levels, a single individual making less than $1252 per month, or a couple making less than $1,691 per month, would be eligible.  More information is available in the Medi-Cal for Low Income Individuals section.

Go Back to Health Reform Information: Individuals and Families