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Individual and Family Health Insurance Plans in California

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Costs for injuries and a non-work related illnesses can be financial overwhelming. Health Insurance can help protect against these unforeseen  expenses and lost wages. Your employer may make medical and disability income benefits available to you. But if you are self employed or your employer does not provide group health benefits, you can purchase a  private California health insurance or through an independent insurance agent who is licensed by the California Department of Insurance to sell health insurance products.

Different types Health Plans and How They Work

Medical Expenses Plans pay expenses incurred for diagnosis and treatment of medical conditions.

 Fixed Allowance Insurance and Reimbursement   

Full freedom-of-choice plans: you choose the doctors and hospitals you want. You choose the dollar amount of the "deductible" to pay before the plan pays anything. After the deductible is met, a percentage of all your expenses is usually covered. The difference between the percentage the plan pays and the amount charged is the "co-amount" that you must pay. The policy or employer benefit booklet will spell out the terms and conditions of what is covered and what in not covered. Read this contract BEFORE you need to use the plan and ask your agent or employer to explain anything which is unclear to you.

Individual Plans: If you are not able to get coverage through your employer, you must get an individual health insurance plan with a California Health Insurance company. Individual plans are fully underwritten, meaning, a series of questions about pre-existing conditions and past illness must be disclosed on the application. The insurance company will decide on the basis of your health history if they will issue the coverage.

Disability Income: An Insurance policy to replace part of your lost wages due to a disabling sickness or injury and you are unable to perform the duties of your job. Disability policies can be set up to pay weekly or monthly. The insurance policy will define the amount you will be paid, how soon after you are disabled payments will begin and how long the payments will last.  Only use licensed California health insurance agents who are knowledgeable about disability income policies.

Supplemental Insurance Policy: Supplemental Insurance Policies pay in addition to your regular medical expenses or disability  income replacement policies. Supplemental insurance should not be used in place of your regular health insurance or disability income coverage. They only pay limited benefits. This coverage may duplicate some of what you are paying for in your California health insurance plan.

 Accident, cancer, hospital indemnity and Medicare Supplements are just some examples of supplemental insurance policies.

  Pre-Paid Contracts

HMO Plans, (Health Maintenance Organizations): With the idea of controlling cost and providing preventative health care before members get sick, Health Insurance companies created HMOs. Comprised of a network of doctors, medical personnel, hospitals,  who have joined the HMO network to provide health care to members in return for a pre-paid monthly fee. In network providers are available as often a as you need for the same pre determined monthly cost and an additional co-pay per office visit and a separate co-pay for prescriptions. Most other medical services are covered in full. You must go to a provider who is part of the insurance company's' HMO network.  You may not go to a doctor or hospital who NOT in the network without first getting prior approval from your carrier.

Some large employers and many labor unions provide "health coverage" for their employees or members without buying an insurance policy from a traditional insurance company. (Some however do hire insurance companies for help). You are self-insured under the Employment Retirement Income Security Act (ERISA) or if it is "insured by" an insurance company. If the plan is self-insured and the employer or the union does not pay a claim, you may have little recourse because these plans are not regulated by the State. Federal labor law governs these plans, but the federal government does not handle claim complaints.

Government Sponsored Medical Expense Programs

Managed Risk Medical Insurance Board (MRMIB) - The California sponsored health care plans for uninsurable individuals. The benefits are limited and there are residency and waiting periods that must be met before benefits are available. Ask your agent for more information or call 1-800-289-6574 for enrollment forms.

Health Insurance Plan Of California (HIPC)-The State of California sponsored a health insurance pool for small employers (3-50 full-time employees). It guarantees coverage to employees in any one of 20 different health plans offered through insurance companies or HMOs at more favorable rates. Your employers can get more information from an insurance agent or by calling HIPC at 1-800-447-2937.

Medicare -a Federal program which provides medical insurance for people over 65 and for those who are permanently disabled. Contact your local Social Security Office for a copy of the current Medicare handbook.

Medicaid- (Called MediCal in California)- is funded jointly by state and federal governments but administered by each state. Medicaid provides medical assistance to low-income families and individual of all ages participating in cash-assistance programs. Medicaid recipients usually do not need private health insurance. Contact your local county Social Services Department for eligibility requirements.

The Health Insurance Portability and Accountability Act


An individual who may have difficulty obtaining individual coverage because of pre-existing medical conditions should contact a qualified health insurance agent and ask for information on "HIPAA-ELIGIBLE, guaranteed-issue" individual health plan. An individual may be eligible to purchase an individual health policy without evidence of good health if she/he meets the following requirements:

  1. The individual, or covered dependent, has been covered under an employer-sponsored health benefit plan, including COBRA or CalCOBRA continuation coverage, for at least 18 months.

  2. The individual terminated employment and must have elected continuation coverage under COBRA/Cal-COBRA.
    All available COBRA/Cal-COBRA continuation coverage has been exhausted; (If an employer terminates its existing group health plan entirely, no more continuation coverage is "available" through that employer or through a successor employer’s plan, continuation coverage has been exhausted).

  3. The individual submits an application, and a "certificate of Prior Coverage" or an acceptable equivalent, for individual coverage to an insurance carrier or an HMO within 63 days of the termination of the group health benefit plan.

The individual does not purchase any kind of other individual coverage, including a conversion policy, a short-term interim plan, the Managed Risk Medical Insurance Plan for uninsurable parties or a medically underwritten individual policy/HMO.

Answers to Questions

Q. What will be asked on the application?

A. To determine your eligibility you will be asked some personal information . Companies screen applicants for individual health insurance, so you’ll fill out an application and answer questions on your medical history. If your information is incomplete or inaccurate regarding health history or age, the company may deny benefits or rescind your coverage. Companies frequently ask physicians for medical records and may require you to take additional physical exams or blood tests However, they cannot ask you for an HIV test, except for disability income and life insurance. People with anything serious in their medical background may be charged a higher price for coverage or may be unable to find individual health insurance at any price

Q. What if I decide I don't want my policy?

A.  You have a "free look" or review your policy.  The free look period varies from company to company and is usually 10 to 30 days. return your policy by certified mail within the required period.  At that time you may request a full refund of the premium you paid when you sent the application in. Group health insurance plans do not have a "free look" period.

Terms that help you with California Health Insurance

  • Assignment Of Benefits - When you assign benefits, you sign a paper allowing your hospital or doctor to collect your health insurance benefits directly from your insurance company. Otherwise, you pay for the treatment and the company reimburses you.

  • Claim - Notification to the insurance company from the policy holder or health care provider (if you have assigned benefits) that a payment is due under provision of the insurance policy.

  • Co-Payment - The amount paid by the patient in addition to any deductible for covered services and supplies.

  • Deductible - The fixed dollar amount that is deducted from eligible expenses before the insurance company pays its share of benefits.

  • ERISA - Employee Retirement Income Security Act (of 1974) The U.S. Department of Labor, ERISA regulates employer-sponsored insurance plans and pension plans for employees.

  • Guaranteed Issue - Coverage that is available available regardless of prior health history employers (between 3 and 50 employees) cannot be refused coverage because of the medical history of one or more employees. Some individual plans are available on a Guaranteed Issue Basis, although premiums are higher.

  •  Limitations - Conditions or circumstances for which benefits are not payable or are limited. It is important to read the limitations, exclusions and reductions clause in your policy or certificate of insurance to determine which expenses are not covered.

  • Medically Necessary   - Insurance policies will pay only for treatment that is deemed "medically necessary " to restore a person’s health. For instance, many policies will not cover plastic surgery for cosmetic purposes.

  • Pre Existing Conditions - Any illness or health problems you had prior to obtaining insurance. Group health care policies will cover pre-existing conditions after you have been covered for up to 6 months; Individual plans up to 12 months.

  • Usual Reasonable Customary - Charges that a carrier determines normal for a medical procedure in a specific geographic area. If the charges and higher than what the health insurance company considers "normal", the health insurance company will not pay the amount of the charged in full. The balance is your responsibility.


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