California Health Insurance Guide
California Health Insurance Information, Health Organizations and Resources and access to online health insurance quotes
As a California resident you can choose from health insurance plans provided to individuals and groups by private insurance carriers. Eligible individuals and families may also take advantage of low-cost and no-cost health insurance offered by California State-funded programs, as well as government-sponsored programs such as Medicaid, COBRA and the Pre-Existing Conditions Insurance Plan (PCIP).
California Guaranteed Issue Policy
California is not a guaranteed issue state for individuals. That means private insurers are not required to sell health insurance to individuals who do not meet their underwriting criteria. You may be turned down, asked to pay a higher premium or offered limited coverage because of a pre-existing condition (see California and the Affordable Care Act below for exceptions regarding pre-existing conditions). When you renew your individual policy, the insurer has the right to increase your premiums based on age and other factors. All small group policies are guarantee issue.
California Guaranteed Renewal Policy
California and the Affordable care Act of 2010
California is a guaranteed renewal state. While your insurance company has the right to increase the premiums on your individual health care policy based on age and other factors, they cannot cancel your policy as long as you pay your premiums, do not defraud the insurers, and in the case of some managed health programs, do not move out of the coverage area. If your California health insurance is provided through an employer’s group plan, your coverage cannot be canceled or subject to higher premiums because of your health.
The Affordable Care Act (ACA) has no direct impact on individual state mandates, however it may have significant impact on some aspects of your health care. As of September 23, 2010:
- Insurers can no longer impose pre-existing condition exclusions on children under age 19. The ban includes both benefit limitations and outright denial of coverage. These protections apply to all types of insurance except individual policies that are grandfathered. Beginning in 2014, these protections will be extended to all ages.
- ACA eliminates the use of lifetime benefit caps on such essential services as ambulatory patient care, hospitalization, emergency services, chronic disease management, lab services, maternity and newborn care, preventive and wellness care, and prescription drugs.
- Health insurance providers must provide full coverage for preventive health care recommended by the Centers for Disease control including immunizations.
- New ACA rules make emergency services more accessible by prohibiting health plans and insurers from charging higher copayments or coinsurance for emergency services obtained out of a plan network.
- ACA allows children under age 26 to stay on their parents’ family policy or be added to it. Grandfathered group plans can limit this benefit to adult children who do not have any other offer of employment-based coverage.
A number of additional ACA mandates are scheduled to go into effect in 2014. Arizona has adopted broad implementation of ACA insurance provisions.
California State Mandated Health Benefits
California currently has over 50 state-mandated benefits that exceed ACA requirements and that private providers must provide or offer in health insurance policies, depending on plan. This is not an exhaustive list and some mandates do not apply to the individual health insurance market.
- Medically necessary basic service including physician, hospital inpatient and ambatory care, diagnostic laboratory, diagnostic and therapeutic x-ray, home health care and hospice
- Cancer benefits for breast cancer testing and treatment, cancer screening including mammography, cervical and prostate, mastectomy and lymph node dissection and patient care related to clinical cancer trials
- Chronic conditions benefits including diabetes management and treatment, HIV/AIDs testing and treatment, HIV/AIDS transplantation services, osteoporosis and phenylketonuria
- Hospice and home health care
- Alcoholism treatment
- Nicotine and chemical dependency
- Mental illness
- Orthotics and prosthetic devices and services
- Pain management benefits for acupuncture, general, general dental anesthesia, pain medication for the terminally ill
- Pediatric care benefits including asthma management and comprehensive preventive care for children 16 or younger
- Reproductive benefits including prescription contraceptives, prenatal testing, infertility treatment and maternity stays
- Surgery benefit mandates for jaw bone or associated bone joints and reconstructive surgery
- Prescription coverage for previously prescribed drugs and off-label use
- Well child care
California also mandates that insurers cannot impose any preexisting conditions for children for plan years beginning after September 23, 2010. California has also adopted broad implementation of ACA insurance provisions and a number of additional ACA mandates are scheduled to go into effect in 2014.
Private Health Care Options in California
Individuals and small businesses in Arizona may chose from a variety of Health Maintenance Organizations (HMO); Preferred Provider Organizations (PPO) and Point-of-Service (POS) plans
Public Health Care Programs in California
- For Individuals and Families –There is a maximum 12-month look back and 12-month exclusionary period for pre-existing conditions for enrollees who do not have proof of prior creditable coverage. Eligibility is subject to medical underwriting. If you are denied coverage because of a medical condition, you may be eligible for Managed Risk Medical Insurance Board (MRMIB) or PCIP. Plan costs including premiums, copayments and coinsurance will vary. There are no caps on individual plan rates.
- For Small Businesses (2 – 50 employees) – There is a maximum 6-month look-back period and a maximum 6-month exclusionary period for pre-existing conditions for enrollees without prior creditable coverage. Pre-existing conditions are covered. Employees must work a minimum of 30 hours per week to be eligible for enrollment. Owner can count as an employee. Costs to employer depend on level of contribution and are +/- 10% of the insurance company’s index rate based on the group’s health status.
- Managed Risk Medical Insurance Board(MRMIB)– Provides eligible applicants with a variety of medical services through HMOs and PPOs. There is a 3-month exclusion for pre-existing conditions.
- Medical-Cal– California’s Medicaid program.
- AIM - Low- and no-cost care for eligible mothers and infants.
- Health Kids– A county-based program providing doctor's visits, immunizations, surgery, prescriptions, dental and vision care to eligible resident children.
- CaliforniaKids– Limited basic health care services for eligible resident children.
- Children Health and Disability Prevention (CHDP) – Preventive care and screening for eligible resident children up to age 5.
Regulatory Agencies and Insurance Information Resources
California Department of INsurance.
300 South Spring Street, South Tower
Los Angeles, CA 90013
National Association of Insurance Commissioners (NAIC)
The National Association of Insurance Commissioners (NAIC) is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. The NAIC provides a forum for the development of uniform policy when uniformity is appropriate. NAIC members are the elected or appointed state government officials who along with their departments and staff regulate the conduct of insurance companies and agents in their respective state or territory.
Insurance Information Institute (I.I.I)
The mission of the Insurance Information Institute (I.I.I.) is to improve public understanding of insurance -- what it does and how it works.
110 William Street
New York, NY 10038