California Health Care Options, From Individual, Family Insurance Plans to State Programs

Health care in California is among the many points which have been raised because the state’s recall election gets under way on September 14.

The Los Angeles Times reported Friday that California Gov. Gavin Newsom argues Republicans are trying to “take away health care access for those who need it,” in accordance to his assertion within the voter information despatched to residents forward of the election.

Health care within the state might be accessed by various types of coverage, from public programs for those on low incomes to individual/family health insurance plans and ones provided through an employer. Each operates underneath their very own guidelines and are regulated by completely different authorities companies.

Here we define the present completely different primary well being care choices accessible to California residents.

Individual and Family Health Insurance

Residents can buy health insurance as an individual if they don’t seem to be lined by way of their employer and don’t qualify for one of many state’s public well being applications.

Once an individual purchases their chosen medical health insurance, family members (in addition to different dependents in some circumstances) might be added to be lined underneath their medical health insurance coverage.

The California Department of Insurance (CDI), which regulates insurance in the state, including health insurance, explains that following the Affordable Care Act (ACA), customers now have extra protections when buying medical health insurance.

As outlined on the CDI website:

  • Insurers can not deny you protection if in case you have a “pre-existing condition.”
  • Insurers can not cost you extra primarily based in your well being standing.
  • The federal authorities affords subsidies to decrease the price of your premium should you meet sure revenue standards.

Residents can contact companies directly to buy individual or family health insurance. See the CDI web site for a list of health insurance companies licensed by the CDI.

Through the Affordable Care Act, California additionally created a medical health insurance market often known as Covered California, by which people, households and small companies should buy medical health insurance from personal insurers.

Covered California additionally helps residents decide whether or not they’re eligible for any public medical health insurance applications, akin to Medi-Cali (extra on Medi-Cal under).

The logo for California Covered.
A emblem for Covered California, a backed medical health insurance alternate and Medicaid administrator for California, seen on a paper in August 2019.
Smith Collection/Gado/Getty Images

Employer Health Insurance and Self-Insured Plans

Employers and different associations buy group medical health insurance insurance policies, that are issued to particular person workers or group members. Depending on the corporate, you could have the option to add members of the family or dependents in your medical health insurance coverage and your employer could require you to pay for a portion or the entire month-to-month premium, in accordance to the CDI.

Many massive firms are self-insured. The CDI says it is crucial to know whether or not your employer is self-insured or not, as a result of you could not have the identical protections and advantages as different varieties of medical health insurance protection. Self-insured plans are usually not required to comply with California legal guidelines on important well being advantages, complaints and protection.

The CDI website says: “Self-insured plans issued by private (non-public) companies follow the Federal Employee Retirement Income Security Act of 1974 (ERISA) and are regulated by the U.S. Department of Labor, Employee Benefits Security Administration (EBSA).” See the EBSA website for extra information.


Medi-Cal is the state’s Medicaid health care program, which provides free or low-cost health coverage to millions of Americans, including those on a low income.

Funded by federal and state taxes, Medi-Cal, which consists of many alternative applications, affords a number of medical companies for kids and adults with restricted revenue and sources, the government’s website explains.

To be eligible for California Medicaid, candidates should be a California resident, a U.S. nationwide, citizen, everlasting resident or authorized alien, in want of well being care insurance coverage help, and “whose financial situation would be characterized as low income or very low income,” explains. They should additionally fall underneath one of many following classes:

  • Be pregnant
  • Be accountable for a kid 21 years of age or youthful
  • Be blind
  • Have a incapacity or a member of the family in your family with a incapacity
  • Be 65 years of age or older

In late July, Newsom signed a bill that expanded the Medi-Cal program to embody undocumented Californians aged 50 and older and prolonged Medi-Cal eligibility for postpartum people.

Some uninsured middle-income pregnant ladies might also be eligible for the Medi-Cal Access Program (MCAP).


Some California residents may also entry Medicare, a federally-funded health insurance program for individuals aged 65 and older, people under 65 with certain disabilities, and people of any age with End-Stage Renal Disease (ESRD), which is a situation of everlasting kidney failure requiring dialysis or a kidney transplant.

The California authorities web site advises that Medicare doesn’t cowl all well being care prices and residents might want to buy different varieties of Medicare-related insurance coverage akin to Medicare Advantage or a Medicare Supplement coverage.

See the CDI website for extra information on Medicare Supplement Insurance (also referred to as Medigap).

HMOs and Managed Care Plans

Health Maintenance Organizations (HMOs) and managed care plans are completely different from conventional medical health insurance insurance policies and function underneath a distinct set of legal guidelines in California. As with medical health insurance insurance policies, the well being care protection might be bought both as “individual/family” or “group” plans, the CDI explains.

For HMOs, you might be restricted to utilizing well being care suppliers inside the HMO community. Those underneath an HMO plan normally have a major care physician, who supplies primary care and might refer you to specialists.

Services accessed from a well being care supplier outdoors of your HMO’s community is not going to be lined by your HMO besides within the case of emergency and pressing care. Other restrictions can apply for HMO plans.

HMOs and Managed Care Plans are regulated by the California Department of Managed Health Care (DMHC).

See the CDI website and the DMHC website for extra information, together with an inventory of managed well being care plans in California.

Protesters in San Francisco.
Protesters demonstrating towards proposed cuts to California’s Med-Cal and Medicare applications, seen outdoors San Francisco metropolis corridor in September 2011.
Justin Sullivan/Getty Images

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