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Health Insurance and Public Coverage
There are many kinds of health coverage. You may have an HMO, PPO, EPO, or fee-for-service coverage. Many people get health insurance through their employer. Some people buy a plan on their own. Other people get health care through public programs. Each type of insurance plan or coverage program has rules that you must follow to get care.
If you have health coverage through a job or union, you have group coverage. Your benefits and costs depend on your employer and the annual group plan they set up with the health insurance company. Often the employer pays part of the monthly premium for the health plan.
Some group plans are self-insured and have different rules and patient rights.
Who is eligible:
- This depends on your employment status and your employer. Some employers cover just full-time employees. Some employers also cover spouses and dependents (including children up to age 26).
How to enroll:
- You often have a limited time to enroll in a group plan after you first start your job or become eligible for the health benefits. Otherwise, you can only make changes to your or your family’s enrollment during the annual open enrollment period or after certain qualifying events (such as marriage or birth of a child). Your employer may have you submit a form to select your plan and tell them who in your household should be covered (if they offer coverage to family members).
- If you leave your job, you may be able to stay enrolled in your employer’s group plan for a limited time through COBRA or Cal-COBRA if you pay the full premium.
For questions about eligibility or enrollment:
- Contact your employer’s human resources office or personnel staff (or union).
For a complaint about your employer’s administration of health benefits:
- Contact the U.S. Department of Labor’s Employee Benefits Security Administration.
- This department oversees certain federal laws that apply to job-based health benefits, including to many self-insured plans.
For questions about using your health plan to get care:
- Contact your health plan’s member services for assistance. Your health plan’s member handbook or website also has information about the plan’s rules and resources for getting care.
For a complaint about your health plan or the providers in its network:
- Contact your health plan’s member services for assistance or to file a grievance.
- If your plan does not help, or for certain urgent health issues, you can file a complaint with the state insurance regulator. For most Californians, the state regulator for health insurance is the Department of Managed Health Care. Learn more about filing complaints.
If you buy health insurance on your own, not through a job or union, you have individual coverage. An individual health plan can cover just you or also cover members of your family.
Under health care reform changes in 2014, individual coverage has more benefits and rights and is similar to group coverage in many respects. For example, individual health plans can no longer deny enrollment to people with pre-existing health conditions or charge them more for coverage because of a health condition.
Who is eligible:
- Anyone can buy individual coverage. If you buy an individual plan through the Covered California marketplace, you will be screened to see if you qualify for assistance to lower your premium cost (based on your household size and income and other eligibility requirements).
How to enroll:
- You can only buy a plan during the annual open enrollment or after certain qualifying events (such as the loss of job-based coverage, marriage, birth of a child, and similar life events).
- You may want to compare health plan policies by visiting the Covered California website or by contacting health plans directly for information about their policies. Or you can contact an insurance broker to help you select your health plan.
- You must pay your premium to the health plan before you will be enrolled.
For questions about Covered California eligibility or enrollment:
- Contact Covered California at 1-800-300-1506 or visit its website www.coveredca.com.
For questions about buying a health plan outside of Covered California:
- Contact the health plan or insurance broker of your choice.
For help using your health plan to get care:
- Contact your health plan’s member services for assistance. You can also find information in your health plan’s member handbook or website about its rules and resources for care.
For a complaint about your health plan or the providers in its network:
- Contact your health plan’s member services for assistance or to file a grievance.
- If your plan does not help, or for certain urgent health issues, you can file a complaint with the state insurance regulator. For most Californians, the state regulator for health insurance is the Department of Managed Health Care. Learn more about filing complaints .
Many Californians have health care supported or administered by a federal, state, or local government program. Public-supported health coverage includes:
Medi-Cal
- Medi-Cal is health insurance for people with low incomes. Children and pregnant women can qualify with slightly higher incomes.
- Most people with Medi-Cal have managed care plans, like HMOs.
- You can apply for Medi-Cal through your county’s Medi-Cal office or the BenefitsCal website. You also can apply for coverage through Covered California.
- To appeal a Medi-Cal decision, you can request a State Fair Hearing. Learn more about a Medi-Cal Fair Hearing.
- For complaints about a Medi-Cal health plan or a provider in its network, contact your health plan’s member services for assistance or to file a grievance.
Covered California
- Covered California is a marketplace where Californians can buy a health plan and often are eligible to receive federal tax credits to help pay the premium.
- Covered California plans are primarily HMOs, PPOs, and EPOs. They are individual commercial plans that Covered California has already screened to make sure they meet standards for benefits and costs.
- You can apply for coverage or find help with enrollment through the Covered California website
- To appeal a Covered California eligibility decision, you can request a State Fair Hearing for an administrative law judge to review your case. Learn more about Covered California appeals.
- For a complaint about a Covered California health plan or a provider in its network, contact your health plan’s member services for assistance or to file a grievance. If your health plan does not help, or if you have an urgent health issue, you can file a complaint with the Department of Managed Health Care.
Medicare
- Medicare is the federal health insurance program for people who are 65 and older, and for some people under 65 who have a disability.
- Medicare Advantage plans are usually HMOs and PPOs. Traditional Medicare (or Original Medicare) is more like fee-for-service health insurance.
- Most people first become eligible for Medicare when they turn 65. Eligibility for Medicare is determined by the U.S. Social Security Administration. Learn more about enrolling in Medicare at www.medicare.gov.
- Medicare has an annual open enrollment period when you can change your health plan or prescription drug coverage.
- Visit the Medicare website for more information about program benefits.
- For help understanding your Medicare options or help with Medicare complaints, contact your local Health Insurance Counseling and Advocacy Program (HICAP). Find your local HICAP by calling 1-800-434-0222 or visiting the Department of Aging’s Services by County webpage.
Cal MediConnect
- Cal MediConnect is a program to coordinate health care for people who are eligible for both Medicare and Medi-Cal and who live in one of the following counties: Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara, and San Mateo.
- People eligible for both Medi-Cal and Medicare can select one Cal MediConnect health plan to receive benefits from both programs. Those who opt out and choose to keep Original Medicare still have to enroll in a managed care plan to receive Medi-Cal benefits.
- For help with a problem with your health plan, contact your plan’s member services for assistance or to file a grievance.
- For help with other Cal MediConnect issues, contact the Cal MediConnect Ombudsman program at 1-855-501-3077.
Veterans Health Benefits
- Veterans health benefits are available to people who served in the U.S. armed forces or were called to active duty in the Reserves or National Guard. The eligibility for care and benefits provided depend on the applicant’s military service history, disability rating, income, and certain other qualifications. Benefits are also available to a small number of family members of certain eligible veterans.
- For help with veteran benefits issues, contact your County Veteran Service Office.
In addition to the full-coverage programs listed here, there are also some programs that provide coverage for specific health conditions or needs. View other resources.
Most Californians have a health plan such as an HMO or PPO that they get through their employer or buy on their own. Most Medi-Cal members also have a managed care plan such as an HMO. Fee-for-service coverage is less common.
Some HMOs, PPOs, EPOs and other plans are high-deductible plans. High-deductible plans have lower premiums but higher deductibles, compared to typical health plans. Higher deductibles usually mean that you pay more out of pocket for health care services before your health plan starts paying its share.
What is an HMO?
- An HMO (health maintenance organization) is a kind of health plan.
- An HMO has a network of doctors, hospitals, labs, and other providers in the plan. You must usually get your care from providers in the network.
- You must have a main doctor, called a primary care doctor.
- You must get a referral from your main doctor for services such as lab tests, x-rays, specialty care, and most other types of care.
- Your HMO or your doctor’s medical group must pre-approve most services.
- You cannot use out-of-network providers unless your HMO gives pre-approval, you have an emergency, or you are traveling and need urgent care.
- You must live or work in the area served by your HMO. This is called the service area.
- Learn more about HMOs.
What is a PPO?
- A PPO (preferred provider organization) is a kind of health plan.
- A PPO has a network of doctors, hospitals, labs, and other providers. These are called the preferred providers. You usually pay less when you get your care from a preferred provider.
- You can use out-of-network providers, but you may have to pay more.
- You can get many services without a referral from your main doctor.
- You can get many services without pre-approval from your PPO.
- Certain services may require a referral or pre-approval.
- You must live in your PPO’s service area.
- Learn more about PPOs.
Other Kinds of Plans
- EPO (exclusive provider organization) is a kind of managed care plan like an HMO or PPO. An EPO has a network of doctors and other providers that you have to use to get care (similar to an HMO). Similar to a PPO, you can usually go to a provider without a referral from your main doctor.
- Point of Service plan is a type of managed care plan that combines the characteristics and rules of an HMO and PPO.
- Fee-for-service insurance (indemnity insurance) usually costs more than HMOs and PPOs, but it gives you greater choice of doctors. Usually, you pay part of each bill, and the doctor bills your insurance company for the rest.
Starting January 1, 2020, Californians must have health insurance or face penalties at tax time.