California, a state in the Pacific region of the United States, is world-famous for its beaches, Hollywood, surfing and wine. California is nicknamed as the land of milk and honey and is sometimes also known as “the El Dorado State”, “the Golden State”, “the Sunshine State”, “the Grape State”, or “the Golden West”. California is the third largest state in terms of land area. With around 39 million people in the state, California is the most populous state in the United States. The state ongoing challenge is to keep a diverse group of people fit and healthy with affordable healthcare options. Therefore, private and small group medical insurance plan in California plays a significant role in maintaining its people healthy and happy.
California was the first state that approved a state-run exchange under the Affordable Care Act in 2010. California’s state exchange is called Covered California and is considered as the country’s most successful exchange. The state has proactively enacted legislation ensuring that the individual market remains stable. The sale of short term plans in California was banned in 2019 as per the California law. As of 2020, California has an individual mandate and a state-based premium subsidy for individuals earning up to 600% of the poverty level.
Latest California Exchange Updates
Open enrollment in California for 2020 health plan coverage has ended but there’s a special enrollment period, through June 30, for the uninsured residents. Residents with off-exchange coverage were allowed till April 30 to switch to an on-exchange plan to take benefits of new subsidies.
- California open enrollment period has been permanently extended that starts from October 15 every year and ends on January 31.
- Starting from 2020, California has a state-based premium subsidy and individual mandate.
- As the new individual mandate the health insurance premiums have been stable in the state and there was just 1% of increase in the premium across the 11 Covered California insurers.
- Over 1.5 million people are enrolled in individual plans through the state exchange, Covered California
- California state exchange is the only exchange in the country offering only standardized plans.
- California state’s exchange is one of the most successful.
- Eleven insurance carriers were offering health plans in 2019 and will continue to offer plans in 2020.
- As per the California law, the sale of short-term health plans has been banned in the state from 2019.
- As of 2020, California has an individual mandate and a state-based premium subsidy for individuals earning up to 600% of the poverty level.
- Enrollment in California’s exchange is second only to Florida.
Individual and Family Health Insurance Plans in California
There are different types of health insurance plans for individuals and families and individuals should compare plans from various providers and select the best health plan that perfectly cater to their exact healthcare needs. with different types of individuals plans available, it is important for people to understand each plan individually and then compare these plans to choose the best plan. People who fail to understand the difference between different individual and family plans, then they can face unexpected costs and disappointment while availing healthcare benefits. In California, following health insurance plans options are primarily available:
PPO or “Preferred Provider Organization” plans are among the popular plans of the Individual and Family segment. Enrollees of the PPO plans are free to visit any in-network physician or healthcare provider of their choice without first requiring to obtain a referral from a primary care physician. Thus, this plan is ideal for individuals who don’t want to get referrals before visiting a specialist, and want absolute freedom in choosing any medical facility or provider for their healthcare needs, and who want a part of out-of-network claims to be covered by their insurance company.
Members of PPO plans are encouraged to use the insurer’s network of preferred doctors and are not required to choose a primary care physician. Members can choose healthcare provider of their choice but they should be aware that in-network healthcare services cover a higher benefit compared to out-of-network services. Members are required to check if their healthcare provider accept their health plan, as this will ensure them with highest level of benefit coverage. Members of PPO plans need to pay annual deductible before insurance company starts covering their medical bills. For certain services, they may also have some co-payment or they may be required to cover a certain percentage of the total cost of their medical bills.
AN HMO or Health Maintenance Organization is a health insurance type having a list of healthcare providers like doctors, medical groups, hospitals, and labs. Members of the HMO plans are required to receive healthcare from the providers included on the list, called as a network. Plan members are required to have a primary care doctor having contract with the HMO, who manage their healthcare. If the members of the HMO plans need to see specialists, require some medical tests, or be in the hospital, then their primary care physician will request authorization and the medical group need to approve the service. Members of the plan are required to pay a co-pay for each received healthcare service. This plan has a service area, so members are required to work and live in the plan area to receive the benefits.
HMO plans offer a wide range of healthcare services through a network of providers who agree to render services to members of the plan. This plan provides coverage for a broader range of preventive healthcare services than one would receive from any other plan. Though there are variations in one HMO plan from another but generally members enjoy lower out-of-pocket healthcare expenses. It is not essential for them to pay a deductible before their coverage starts and even their co-payments are likely to be minimal. Members typically don’t have to submit any of their claims to the insurance company. Though, enrollees should be aware that they will likely have no coverage for healthcare received by out-of-network providers or for medical services rendered without a proper referral from their PCP. This type of plan is ideal for people who are looking for lower premiums plans, want to purchase plan that don’t have deductible and are not concerned for having an out-of-pocket limit. People who require preventive care services like coverage for checkups and immunizations will also prefer this plan.
EPO or Exclusive Provider Organization Plan
Exclusive Provider Organization is a mix of the HMO and PPO plans and is growing in popularity in California. Members of the EPO plans enjoy the same freedoms as the members of a PPO plan. Just like PPO plan, members of EPO plan too don’t require to have a primary care physician to manage their healthcare and to provide a referral every time they wish to visit a specialist. Members of EPO plans have an exclusive network of healthcare providers, which they are required to use. The network of EPO plan is much like the network of the HMP plan. Just like the HMO plan, members of EPO plan will be covered out-of-network but only in case of medical emergency. EPO plan is comparatively cheaper than a PPO plan and proves to be an excellent option for people who wish to have good control over their healthcare without paying significant amount in insurance premiums. Members of this plan should be aware that if they visit a doctor who is not in the EPO network, then they are responsible for all the healthcare costs.
Medi-Cal Managed Care Plans
Medi-Cal is a managed care plan designed for low or no income people of California. These plans have its networks of providers like doctors, pharmacies, clinics, labs, and hospitals and members are expected to receive healthcare services from the in-network healthcare providers. Medi-Cal plans cover all the basic benefits covered by other major plans and also provide coverage for prescription drugs, vision care, and hearing care. Members of the plan are provided with a doctor or clinic to whom they can visit for most of their healthcare need. The doctor or clinic are chosen by the health plan for the members joining the plan. Though, members can change their doctor or clinic if they wish to and can call the plan and ask for a list of doctors and clinics. Individuals can qualify for Medi-Cal through many ways, though their income and health problems are majorly taken into consideration.
Short-term Plans in California
California no longer allows the sale or renewal of short-term plans in the state. A bill was passed in 2018 by the lawmakers in California that prohibits the sale or renewal of short-term plans in California as of January 1, 2019. Thus, short-terms plans are no longer available for purchase or renewal anywhere in California.
Dental Plans in California
Dental insurance in California works in the same manner as the medical insurance. Individuals having dental insurance are required to pay a monthly premium to receive certain dental benefits. Benefits that are included in dental insurance include regular checkups, cleanings, x-rays, and services required to promote general dental health. Some of the dental plans provide broader coverage compared to other plans, and with some dental plans members require a greater financial contribution while receiving dental care services. Some of the dental plans in California provide coverage for certain types of oral surgery, dental implants, or orthodontia.
Dental insurance plans are categorized as the following plans:
Indemnity Dental Plans – This type of dental plans in California provides a broader selection of dental care providers. In an indemnity dental plans, the dental insurance carriers pay for the covered dental care only upon receiving a bill, which means that members have to pay for the dental care up front and later on obtain reimbursement from their insurance carrier.
Managed Care Plans – A network of dental care providers is maintained in the managed care plans. The dentists of California are included in the network who agree to render dental care for patients at pre-negotiated rates. The dental care providers usually submit the claim to the dental insurance company for the members. People have less paperwork and lower out-of-pocket costs with a managed care dental plan and a broader choice of dentists with an indemnity plan.
Vision Care Plans
Vision insurance helps people maintain their eye wellness, and also help to maintain their overall health because eye exams can also detect common health problems like diabetes and high cholesterol. People in California can buy vision insurance plan by itself or they can add to their health insurance or dental insurance plans. Vision insurance provide coverage for eye check-ups and eye exams and members also get allowances for the glasses or contact lenses.
Insurance Carrier in California
The 11 insurance carriers offering health plans through Covered California in 2020 include:
- Anthem Blue Cross of California
- Blue Shield of California
- Chinese Community Health Plan
- Health net
- Kaiser Permanente
- L.A. Care Health Plan
- Molina Healthcare
- Oscar Health Plan of California
- Sharp Health Plan
- Valley Health Plan
- Western Health Advantage