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Your Right to Health Care Coverage
There are laws that protect people applying for health coverage and health plan members. If you have questions about these rights, look at your plan handbook or contact the agency that oversees your plan.
Your right to buy health coverage
- Health plans cannot refuse to cover you or charge you more because you have a health problem or are pregnant.
- Plans cannot charge you more because you are a woman.
- Plans can only consider your age, geographic region, and family size when determining your monthly premium cost.
- Children can stay on their parent’s or guardian’s health plan until age 26.
- Plans must accept you if you apply during an open enrollment period or qualify for a special enrollment period. This is known as guaranteed issue.
- Plans will deny you if you apply after open enrollment ends, unless you qualify for a special enrollment period after a qualifying life event (such as marriage, birth of a baby, loss of a plan through a job, and other changes).
- During an enrollment period, plans are only allowed to deny you for a very limited number of reasons. These reasons include if you don’t live in the plan’s service area or if the plan doesn’t have enough doctors in its network to serve any new members.
Your right to benefits and services
- You have the right to learn if a service is covered by your health plan and what it will cost you.
- You can call your health plan to find out if a test or procedure is covered and if it requires pre-approval.
- You can ask your health plan to help you clearly understand the services it covers.
- You can ask your plan to explain your bills and make sure the charges are correct.
- Most plans must cover a complete set of benefits, called essential health benefits. Essential health benefits include doctor and specialist visits, chronic disease management, dental and vision care for children, emergency services, hospital care, lab services, maternity and newborn care, mental health and substance abuse services, many prescription drugs, rehabilitation services and equipment, and preventative and wellness services. If you have an older (“grandfathered”) plan, your plan might not cover all of these benefits.
- Many health plans must offer no-cost preventive care, such as vaccines and cancer screening. You do not pay a co-pay, co-insurance, or deductible for these services.
If you go to the emergency room for a health emergency, the plan must pay for that care. You can go to the nearest hospital, even if its not in your health plan’s network. - Most plans cannot put an annual limit or a lifetime limit on costs they pay for essential health benefits. This means they cannot put a limit on paying for your care if you get sick.
- Your plan must let you see a specialist if you need one.
Your right to keep health coverage
- Health plan cannot cancel your coverage just because you get sick or make an unintentional mistake on your application.
- Health plans generally cannot cancel your coverage unless you did not pay your premiums or you did not fill out your application truthfully.
- A health plan has to give you notice if your coverage is ending. Sometimes you also must be given the option to enroll in a different plan.
- If you lose your coverage, you may qualify for a special enrollment period to get a new health plan.
- If you lose your plan through your job, you may have the option to keep buying that same plan through COBRA or Cal-COBRA.
Prescription Drug Coverage
- Most health plans are required to cover prescription drugs.
- Not all plans cover all medications. The list of prescription drugs that a plan covers is called a formulary. You can check your plan’s formulary to see which prescriptions are covered and how much they will cost.
- How much you pay will depend on your plan. Some plans have different deductibles or copays for prescription drugs. Check your plan for details.