If You Lose Your Group Health Benefits

If you lose your job or your hours are cut, you may also lose your group health benefits.

• You may be able to buy continuation health coverage.
• Or you may be able to buy an individual policy .
• Or you may qualify for a public program .
• Or you may be able to get on your spouse or partner’s group insurance. Try to do this as soon as possible, to avoid a gap in coverage.

You can keep your employers health coverage

You and your dependents may be able to keep your existing health coverage even if you lose your group health benefits. These options are called continuation coverage.

If you lose your coverage, your employer must provide you with information on your options for continuing your existing coverage. You may see options with names like COBRA, Cal-COBRA, Conversion or HIPPA. If you choose one of these options:

• You have to pay all of the premium.
• After you use up one kind of continuation coverage, you may be eligible for another kind of coverage.
• There are deadlines and other requirements for each kind of continuation coverage.

If you have any questions about your options, contact the Consumer Hotline at the Department of Insurance 927-4357 for assistance.

Continuation Coverage or an Individual Policy?

Buying Individual Health Insurance on Your Own

People usually buy individual health insurance because they do not have group insurance through a job and they do not qualify for any public program.

Medi-Cal

What Happens If My Doctor Recommends Care That Isnt Covered By My Insurance

Most of the things your doctor recommends will be covered by your plan, but some may not. When you have a test or treatment that isnt covered, or you get a prescription filled for a drug that isnt covered, your insurance company wont pay the bill. This is often called denying the claim. You can still obtain the treatment your doctor recommended, but you will have to pay for it yourself.

If your insurance company denies your claim, you have the right to appeal the decision. Before you decide to appeal, know your insurance companys appeal process. This should be discussed in your plan handbook. Also, ask your doctor for his or her opinion. If your doctor thinks its right to make an appeal, he or she may be able to help you through the process.

Reasons Your Health Insurance Wont Pay For The Care Your Healthcare Provider Says You Need

1. What you need isnt a covered benefit of your health plan.

When your health plan denies your claim or refuses your pre-authorization request for this reason, its basically saying that your policy doesnt cover that test, treatment, or drug no matter what the circumstances are.

Your insurer should know exactly what benefits your policy provides and what isnt covered, but sometimes your insurer is wrong. Check your policy carefully. If your health insurance is through your job, check with your employee benefits office to see if you actually do have coverage for the service your health insurance says isnt covered.

In the United States, small group and individual health plans with effective dates of January 2014 or later have to cover the Affordable Care Act’s essential health benefits. But large group employer-based plans and grandfathered/grandmothered plans dont have to provide this same coverage.

If you feel youre being denied the benefits of coverage your policy says you actually have, follow the appeals procedure your health plan booklet outlines. Also, enlist the help of your employee benefits office if your coverage is job-based, or your states insurance commissioner .

2. You got the care from an out-of-network provider when your health plan coverage is limited to in-network providers.

However, if youve already gotten the care and your health plan won’t pay your claim because you went out-of-network, youre going to have a more difficult fight on your hands.

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Types Of Private Health Insurance

While you should review your specific plan in detail in order to understand the services it covers and how it covers them, a summary of types of plans is helpful to understanding the way that claims are processed and, at times, denied.

A Health Maintenance Organization is a type of plan in which you must choose an in-network primary care physician to oversee your treatment and health needs. An HMO will cover care from a specific network of providers, but many kinds of care are subject to some out-of-pocket costs to you.

A Preferred Provider Organization is similar to an HMO in that it covers treatment through a network of providers, but it allows you to receive treatment from providers outside of the insurance plans network. In both cases, you will likely pay some amount out-of-pocket, but a PPO will tend to cover more of the cost of care you receive from an in-network provider.

A Point-of-Service plan covers care from providers outside of your network if your PCP has made a referral. If you refer yourself outside of the network, your coverage may be denied or a higher coinsurance required.

Some HDHPs are HSA-Qualified. People who are enrolled in an HSA-Qualified HDHP are allowed to set money aside in a tax-advantaged Health Savings Account . Money in an HSA can be used to pay for certain health care expenses, which can prove a great help to consumers when they need to pay the deductible amount.

The Affordable Care Act Obamacare

The Patient Protection and Affordable Care Act is a federal statute signed into law by President Obama, which made it mandatory for every citizen to have health insurance or be penalized. The Act subsidies for low-income families, by taxing healthcare providers and high-income families, as it was designed to lower health care costs while providing better health care for Americans.

The Affordable Care Act allowed parents to ad their children up to the age of 26 to their policies, in a bid to have younger healthy people paying premiums. It also allowed poorer people to get treatment for chronic illnesses instead of using the emergency room.

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What Is Comprehensive Coverage

Comprehensive coverage when were referring to health insurance, as opposed to automobile insurance refers to a health plan that provides broad coverage of a wide range of healthcare services such as physician visits, hospitalization, and emergency room visits. Covered care can be preventive or provided to treat injury or illness. Comprehensive health insurance coverage is also known as major medical health insurance.

All new individual/family and small-group major medical policies sold after January 1, 2014, must cover the ten essential health benefits outlined in the Affordable Care Act with no annual or lifetime benefit caps.

Major medical plans that were in effect prior to March 23, 201 can still remain in effect, but can no longer be sold to new individuals or employer groups. And major medical plans that were in effect in the individual and small group markets prior to 2014 can still remain in effect in most states, although they also can no longer be sold. These grandfathered and grandmothered plans are considered comprehensive, but they are generally not as robust as post-2014 policies, and do not include all of the same consumer protections.

What Doesnt Health Insurance Cover

The ten essential benefits cover many healthcare needs, but theres no requirement that a health plan must cover other additional services. If youre looking to switch to a new health insurance policy, there could be several services you think are covered, but theyre not.

Outside the ten essential benefits, an insurance company determines what kinds of services they want to cover. These decisions are based on the companys understanding of the types of medical care most patients need and what they can offer while still remaining profitable.

Understanding your health coverage plays a big part in how much youll pay out-of-pocket, including your deductible, coinsurance, and copay. It can also help you determine if you need to purchase supplemental health insurance.

Lets look at three popular healthcare services often not covered by standard health insurance plans.

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How Much Will It Cost

Understanding what insurance coverage costs is actually quite complicated. In our overview, we talked about paying a premium to enroll in a plan. This is an up front cost that is transparent to you .

Unfortunately, for most plans, this is not the only cost associated with the care you receive. There is also typically cost when you access care. Such cost is captured as deductibles, coinsurance, and/or copays and represents the share you pay out of your own pocket when you receive care. As a general rule of thumb, the more you pay in premium up front, the less you will pay when you access care. The less you pay in premium, the more you will pay when you access care.

The question for our students is, pay now or pay later? Either way, you will pay the cost for care you receive. We have taken the approach that it is better to pay a larger share in the upfront premium to minimize, as much as possible, costs that are incurred at the time of service. The reason for our thinking is that we dont want any barrier to care, such as a high copay at the time of service, to discourage students from getting care. We want students to access medical care whenever its needed.

Do I Need Private Health Care Coverage When Travelling Outside Canada

While travelling within Canada, the portability criterion of the Canada Health Act requires that insured hospital and physician services are covered at host-province/territory rates. When outside the country, coverage is required to be at home-province/territory rates. As a result, health care services received abroad may not be fully covered by a provincial or territorial health insurance plan. For that reason, it is highly recommended that you purchase private insurance before departing Canada, to ensure adequate coverage.

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How Will My Health Plan Cover A Covid

The CARES Act requires all non-grandfathered health plans, including private insurance, Medicare, and Medicaid, to cover COVID-19 vaccines without any cost-sharing for the member .

The full coverage of COVID-19 vaccines includes both the vaccine itself and any charges from the provider or facility for the administration of the vaccine. The COVID-19 vaccine has been added to the list of recommended vaccines, and the CARES Act required private health plans to begin fully covering it within 15 business days much faster than the normal timeframe between when a preventive care recommendation is made and when insurers have to cover it with no cost-sharing. This applies to all COVID vaccines that have received FDA approval, including emergency use authorizations. As of April 2021, that includes vaccines from Pfizer, Moderna, and Johnson & Johnson.

How Do I Register A Complaint Against A Doctor

Since the provinces and territories, rather than the federal government, are primarily responsible for the administration and delivery of health care services and the management of health human resources, you should contact your local provincial/territorial Ministry of Health – the phone numbers and websites are located inside the back cover of the current Canada Health Act Annual Report. You can also contact your province or territory’s College of Physicians and Surgeons, which is the organisation that governs physician licensing and conduct. Links to each provincial and territorial medical regulatory authority can be found on the College of Physicians and Surgeons of Canada website.

Canada Health Act Division

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Understanding Health Insurance Costs

Having insurance doesnt mean your health care will be free. Youll still pay a monthly rate, or premium. Members may also pay copayments or other out-of-pocket fees or have to meet deductibles every year before insurance coverage kicks in.

Different factors can affect your health insurance costs. Its important to understand what these costs are before selecting a plan.

Why You Need Health Insurance

No one plans to get sick or hurt. Its just a part of life. But if youre without a health insurance plan, illness and injury can quickly become devastating to your health and leave you overwhelmed with medical bills and expenses. Health insurance can limit your risk of paying for expensive illnesses and injuries by covering a portion of your medical care and other services, like a hospital stay or surgery.

Ultimately, health insurance can help you stay healthy even when youre not sick or hurt. Preventive care, which can be as simple as an annual visit with your doctor for a check-up and getting your recommended screenings, means that youre more likely to avoid or significantly reduce the chance of developing a more serious condition later on.

You may even be eligible to participate in covered well-being programs, or receive discounts on health products and services.

Tell us what other health insurance topics you would like to learn about. We are looking for feedback on what to include in updates to the site.

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What To Do If You Have A Problem With Your Policy

Contact your health plan to resolve your problem.

• Talk to your doctor and call your health insurer. Sometimes talking solves the problem.
• You can file a complaint with your health plan. A complaint is also called a grievance or appeal.
• Generally, your insurance company must make a decision within 30 days.
• If your health problem is urgent, your health insurance must do an Expedited Review. It must be done as soon as possible, in 72 hours or less.

If you are not satisfied with your health plan’s review process or decision, call the California Department of Insurance . You may be able to file a complaint with CDI or another government agency.

If your policy is regulated by CDI, you can file a complaint at any time. The CDI reviews cases that involve:

• Disagreements about the services your health plan must cover.
• Termination or cancellation/rescission of your insurance policy.
• Exclusions and limits on services that are usually covered.
• Timely access to medical care.

My claim was denied. Now what?

Your health insurance policy tells you how to appeal if your plan denies your claim or pays less than you think it should.

You have a right:

• To receive an explanation of your plan’s grievance and appeal procedures.
• To file a complaint, also called a grievance or appeal, with your plan.
• To receive an easy-to-understand written decision on your appeal.
• To file a complaint with CDI, Call 1-800-927-4357 or visit www.insurance.ca.gov.

Independent Medical Reviews

What Doesn’t Health Insurance Cover

Health insurance plans typically won’t cover procedures or treatments deemed medically unnecessary, including:

• Cosmetic procedures
• Off-label prescriptions
• New medical technologies

If you’re denied coverage for a procedure or treatment your doctor says is necessary, you can appeal your insurer’s decision. Sometimes, insurers may approve coverage upon further review of your case, including any supporting documentation your doctor can provide.

Pro tip:

Some health care services require preapproval or prior authorization from your insurance provider before care is given . Typically, your doctor will start the approval process and provide any additional information your insurer needs to review. Preapproval can be required for hospital stays, specialty drugs, and other complex treatments.

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Common Health Insurance Terms

Deductibles, premiums, network, claims, benefits what do all these words actually mean? Health insurance practically seems to have a language of its own. To make it easier, you can check out our list of common terms and get quick definitions that help explain what they mean in everyday language.

Treatment In Blacklisted Hospitals Is Not Covered Under Health Insurance

Some hospitals or doctors are blacklisted by health insurance companies because of their bad public image. In case you get hospitalized in a blacklisted hospital or are getting treatment from a doctor that your health insurance company has blacklisted, you may be denied a claim.

However, in case of an emergency such as an accident or a life-threatening situation, your insurance policy may cover your medical bills until your condition is stable. Once the condition is stable, you should be immediately admitted to a hospital that is in the network of the company.

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What Does The Plan Cover

One of the things health care reform has done in the U.S. is to introduce more standardization to insurance plan benefits. Before such standardization, the benefits offered varied drastically from plan to plan. For example, some plans covered prescriptions, others did not. Now, plans in the U.S. are required to offer a number of “essential health benefits” which include

Emergency servicesPreventive services and management of chronic diseasesRehabilitation services

For our international population of students who might be considering coverage through a non U.S. based plan, asking the question, “what does the plan cover” is extremely important.

Health Insurance Open Enrollment

Open enrollment is a special period of time when you get to start, stop or change your health insurance plan. This period most often happens once a year . There are different enrollment periods depending on if you have insurance through your employer, Medicare or an ACA plan.

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Covered California: California’s Healthcare Marketplace

As part of the Affordable Care Act, California created a health insurance marketplace called Covered California. Through Covered California, individuals, families, and small businesses can purchase insurance products sold by private insurers. Covered California also helps individuals and families determine if they qualify for the Medi-Cal program and subsidies from the federal government toward purchase of a private insurance plan. Visit Covered California for more information about getting coverage.