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California Health Insurance

California Medical Insurance Overview

California offers many options when it comes to health insurance programs on offer to its residents. These programs range from individual plans, public assistance and employer-sponsored health plans. Despite the options available to the state’s residents, many people in California still do not have health insurance. With the new health care reform coming into play, residents of California may find it easier to get insurance coverage despite their financial status or the presence of any pre-existing conditions. The information listed below talks about the health care problems in California in addition to the health insurance options that Californians can select from when seeking insurance coverage.

California’s Health Care Issues

The state of California is ranked at 22nd when it comes to the health of its residents when compared to the rest of the nation as a whole. The study provided by the United Health Foundation gives California’s strengths and weaknesses with regard to the health status of those living in this state.

Understanding The Uninsured Population of California

There is a wide variety of data available on the population of California residents who do not have health insurance given to us by the Health Care Almanac. The state had the highest amount of uninsured individuals in the state of California in 2011, with that number rising in the last two decades. The percentage of residents covered under an employer-sponsored plan has declined in recent years, dropping from 65 percent to 52 percent since 1987. State-funded programs tried to fill in the gap of the uninsured population, but the uninsured population of the state of California is still roughly 20 percent.

Other statistics from the Almanac’s report show the following data:

  • Three quarters of those individuals working in California had insurance, while the other 25 percent did not.
  • Those working in the state of California are more likely to be without insurance when compared to the entire U.S.
  • Nearly a third of those working in California who do not have insurance earn an annual salary of $50,000 or more.
  • In 2011, over half of the children who were uninsured have a family member who had full-time employment and was the head of household.
  • Out of those individuals without insurance in the state of California, three out of five of the people are Hispanic.

Group Health Plans

Your workplace or union typically offer health insurance coverage through a group plan with coverage made available to retirees as well. These plans are cheaper overall than individual plans, but your employer will have to pay for part of your premiums. The Department of Managed Health Care regulates the group health insurance plans in California.

Signing Up

When you get a new job, you should speak with the Human Resources Manager to ask how to go about signing up for the employer-sponsored coverage.You will want to consider the following:

  • Take a look at each of the available plans and contemplate the pros and cons of each to find one that meets your needs for medical services.
  • Figure out the enrollment period for your employer-sponsored plan. This time frame typically occurs once per year and will also give you the chance to make adjustments to your coverage.
  • In this state, any minor children you have can remain covered under the terms of your insurance policy until they reach the age of 26. There are plans available that will allow you to put your domestic partner onto your policy, but this could cause an increase in the amount you pay for monthly premiums.

Pre-Existing Condition Exclusion Periods

Pre-existing conditions are illnesses, disorders, injuries or diseases that you have had prior to enrolling in your health insurance plan. In the state of California, you cannot be turned down for coverage on an employer-sponsored plan due to a pre-existing condition. In some of these cases, exclusion periods are applicable. An exclusion period typically causes your plan’s benefits to be delayed for anywhere between six and twelve months if your plan has less than two members.

The following information represents other things to keep in mind when discussing exclusion periods for pre-existing conditions with regard to a group health plan in the state of California:

  • There are no exclusion periods for children age 19 and under even in the presence of a pre-existing condition.
  • If you have been covered under a different plan for a period of one to six months, the exclusion period should be lessened.
  • If you have not received care for your pre-existing condition for six months prior to your application for your employer’s health plan, then you cannot be excluded for services.
  • If you have had insurance coverage in the six months before getting new insurance coverage, the group health plan of which you’ve signed up cannot excluded you from receiving medical services.

Waiting Periods

There are a variety of health plans that will require you to wait out a waiting period before you can begin using the benefits of which you have signed up. Under the law in the state of California, you cannot be made to wait a longer period than sixty days and you won’t be asked to remit payments for premiums during that time. Also, if you have a waiting period imposed on you, then the insurance company is not able to enforce an exclusion period because of a pre-existing condition as well.

Individual Health Insurance Plans

People in California are able to purchase individual health insurance coverage on their own. As of the year 2014, health insurance providers no longer had the opportunity to refuse health insurance because of a pre-existing condition or to charge higher rates for coverage. The new health insurance marketplace in California exists to provide individuals with affordable coverage through individual health plans.

Prior to the year 2014, if you had a certain health problem, you may have found it difficult to get coverage under the terms of an individual insurance policy. For those individuals who are 19 and older, the plan was able to refuse coverage or charge a premium amount that was typically higher than normal. These plans also could make you wait out an exclusion period because of any pre-existing conditions.

The Department of Managed Health Care has stated that according to the law, those children aged 18 and under who have pre-existing conditions cannot be denied or limited coverage by an individual plan. Because of the health care reform that took place in 2014, those plans had the chance to make applicants pay out higher premiums to cover children with pre-existing health conditions.

California Health Benefit Exchange

The health insurance marketplace in the state of California began in 2014 with the purpose in giving all of the residents in the state access to affordable health insurance benefits. The plan’s target was to provide easy to obtain coverage that would cost less and be of a higher quality. This is taken care of through the health insurance marketplace that gives consumers the chance to select their own health insurance provider and policy that gives them the best care and value.

Through the state of California, the health insurance marketplace is offered under a program called Covered California. In January 2014, this plan went into effect and it gives people a place to select insurance coverage and receive financial assistance. Under this plan, insurance providers are unable to deny or drop your insurance coverage because of a pre-existing condition.

Covered California seeks to increase the number of Californians who have insurance and estimates have shown that 2.6 million residents will be allowed to qualify for financial assistance from the government in order to help with their health care costs. In the state of California, 2.7 million residents probably won’t qualify for help with their financial issues, but they can still seek insurance coverage and not get turned down. Over two million people living in the state will be enrolled under the health insurance policy brought forth by Covered California by 2017.

Residents will have the chance to buy coverage that is also available through private insurance companies. The benefit of using Covered California is that consumers can do comparison shopping online and find the best coverage through the plan’s ranking algorithm. In order to aid in lowering the costs of health insurance, individuals in California can also use cost-sharing subsidies and tax credits through Covered California.

Covered California is also working to help out those who own small businesses in the state by offering insurance coverage to workers at lower overall costs. By using the benefits marketplace, those businesses with fewer than fifty full-time workers can purchase health plans. Those businesses with less than 25 employees that are full-time can seek information related to a tax credit. In 2015, bigger companies were able to use the services of Covered California in order to help meet their needs for health insurance coverage.

California State Insurance Plans

There are many different programs offered by the state of California’s Department of Health Care Services that help to provide for the health services for both individuals and families who have lower than normal incomes. Here is a list of some of the most common programs that are offered.


This is California’s state Medicaid program, which is a public health care insurance program that is designed to provide different services for lower-income individuals. These include the following:

  • Individuals who suffer from disabilities
  • Families who have children
  • Anyone under foster care
  • Seniors
  • Individuals who suffer from certain diseases

If you wish to apply for Medi-Cal, visit your nearest social services office. If you are someone who receives payments through either SSP or SSI, then you will automatically qualify for Medi-Cal and will not need to apply. Instead, your coverage will be established for you through the Social Security Administration. If you apply for coverage and do not have a disability, you must submit your application within 45 days.

In the event that your income is lower than what Medi-Cal has established for a family of your size, you will be able to receive complete coverage at absolutely no cost to you whatsoever. However, if the opposite is the case and your income is over these limits, you will likely be required to pay a certain amount of money during the time in which you utilize Medi-Cal’s services.

Access for Infants and Mothers (AIM)

This is a service that is designed to assist mid-income pregnant women throughout California. In order to qualify for this program, you must be no more than 30 weeks pregnant. Additionally, this program also offers coverage at a lower cost for pregnant women who do not have insurance, yet who have incomes that are too high in order to apply for assistance through Medi-Cal. Women will also be able to apply for assistance through AIM if they have health insurance with either a deductible or a co-pay for any maternity-only services that equal $500 or more. If a pregnant woman gives birth to a baby while receiving assistance through AIM, these children will be eligible to receive help through Medi-Cal thanks in large to current changes in the state law that will put an end to the Healthy Families program.

Every Woman Counts (EWC)

This is a service that provides breast examinations, mammograms, pelvic examinations, and pap smears to under-served women absolutely free of charge. There are, however, certain eligibility requirements that must first be met, such as the following:

– Breast Cancer Screening

  • 40 years of age or older
  • Lower than average income
  • Resident of California
  • Possess insurance that will not cover screenings
  • Have either a high insurance deductible or copay
  • Ineligible for Medi-Cal

– Cervical Cancer Prevention

  • 21 years of age or older
  • Lower than average income
  • Resident of California
  • Possess insurance that will not cover screenings
  • Have either a high insurance deductible or copay
  • Ineligible for Medi-Cal

Breast and Cervical Cancer Treatment Program (BCCTP)

The BCCTP service provides cancer treatment to those who have received a positive diagnosis of either cervical cancer or breast cancer. Individuals can receive full Medi-Cal coverage through this program as long as the following requirements are met:

  • Resident of California
  • 65 years of age or younger
  • Possess no health insurance
  • Monthly family income of 200% or less than the average federal poverty level

Women, Infants, and Children Program (WIC)

This program is designed to benefit women, infants, and younger children throughout California by providing financial assistance for purchasing food through qualified WIC vendors. In order to qualify for WIC, women who are either pregnant or who have a child that is under age five must meet certain guidelines in terms of income.

Multipurpose Senior Services Program
This is a program that offers health care management services to senior citizens who may be at risk of being placed in nursing homes, yet wish to remain in their own homes.

California Newborn Screening Program
This program screens newborns throughout the state in order to determine whether or not they have certain disorders.

Indian Health Program (IHP)
This program is design to help improve the health of Native Americans living in various types of communities throughout California.

Health Insurance Premium Payment (HIPP)
This program is designed to reimburse individuals who have either Medi-Cal or private insurance for medical costs.

Prostate Cancer Treatment Program
This program is designed to help underserved men throughout the state receive various treatment services regarding prostate cancer.

Also known as the California Mental Health Care Management Program, this is a program that is dealt through a partnership between the Department of Mental Health and the Department of Health Care Service.

Major Risk Medical Insurance Program (MRMIP)

This program is designed for individuals who have both serious health issues and pre-existing conditions, yet are unable to afford health insurance of any kind. In order to qualify for this program, participants must be California residents and pay premiums for the cost of their coverage before the state supplements that cost in order to cover the total cost of the care that is provided. This is a program that often has a waiting list, meaning that funding is sometimes limited.

Further eligibility requirements include the following:

  • Ineligible for either Medicare Part A or B, unless eligibility is based on having end-stage renal disease
  • Unable to obtain medical coverage
  • Ineligible for benefits under either Federal COBRA or Cal-COBRA

Pre-Existing Condition Insurance Plan (PCIP)

This program is designed for individuals who have been denied health care coverage due to any kind of a pre-existing condition.

Further eligibility requirements include the following:

  • Resident of California
  • No health coverage for the past six months
  • Denial letter from a private health insurance company within the past year

Federal and Cal-COBRA

Federal COBRA, mandated by United States law, applies to group health insurance plans that offer coverage to approximately 20 employees and allows individuals to keep their insurance if they either lose their job or their hours are cut. Cal-COBRA is mandated by California state law and states that individuals may keep their current health insurance for no more than 36 months if a plan has between two and 19 employees. This is an option that is also available to those who have exhausted their options in terms of Federal COBRA. Here is the basic outline:

– Small Employers (2-19 Employees)

  • Cal-COBRA (36 month coverage possibility)
  • Cal-COBRA (18-month coverage if Federal COBRA coverage ends at the same amount of time)
  • After COBRA ends

– Large Employers (20 Employees or More)

  • Federal COBRA (18 to 36 month coverage possibility)

There are also many different insurance options available once either COBRA option expires, which include the following:

  • Enroll into a HIPAA plan
  • Purchase an individual health plan
  • Convert to an individual plan through a conversion coverage plan
  • Enroll in a high-risk plan

HIPAA/Conversion Health Plans

Also commonly referred to as the Health Insurance Portability and Accountability Act, HIPAA enables individuals to purchase individual health plans whenever they lose group health plan coverage, even if the individual has any kind of a pre-existing condition; according to the Department of Managed Care. Additionally, you cannot be denied coverage due to your previous medical history. In order to qualify, you must meet certain requirements depending on the particular plan that you sign up for. Some of these requirements include the following:

  • Coverage for the past 18 months through a group health plan offered by an employer
  • Federal COBRA and Cal-COBRA have been exhausted
  • Possess no other health insurance
  • Any health insurance that has been lost cannot have been done so due to failure to pay premiums, deception, etc.

Conversion plans are ones that are offered by your group health insurance plan after your initial coverage has ended. If you find that you are eligible for this, you will not be able to be denied coverage due to your previous medical history; however, you will be required to pay monthly premiums. Furthermore, you will also need to first make sure any Federal COBRA and/or Cal-COBRA programs have first been exhausted.