The state of California, having the highest population of more than thirty six million citizens, has both private-market and public health insurance alternatives. The private-market health insurance comprises of numerous types of health plans including family, Medicare supplemental, short-term, student, group and dental. Additionally, the state and federal government sponsored programs provide inexpensive health coverage to the uninsurable residents of California who meet specific eligibility requirements of age, income and health status.
The California Department of Insurance is responsible for regulating all types of insurance sold in the state of California including health insurance policies offered by private-market health insurers or public health coverage programs. However, approximately 18.5% of the population remains uninsured, as state strives to improve the standards of healthcare quality for its citizens. According to the Censor Bureau’s 2007 and 2008 Current Population Survey, approximately 34.1% of uninsured Californian residents come under the above 200% FPL category.
Shopping for affordable health plan for your family can truly be exhausting and perplexing. In the wake of high health care costs, you need the guidance of a licensed health insurance agent/broker, when it comes to gaining from health insurance benefits.
Individual/Family Health Insurance
Below is the guidelines for applying for and obtaining individual health insurance in the state of California. These regulations apply to all insurance companies offering individual or family health insurance in California:
Medical Underwriting
Yes
Pre-Existing Condition Exclusion Period
12 months
Look Back Period
12 months
Look Back Standard
Objective
Mandatory Benefits
Cancer screening for women including breast cancer screening and cervical cancer screening, minimum IP mastectomy stay as determined by the surgeon, reconstructive surgery after mastectomy, screening, diagnosis and treatment of osteoporosis, infertility diagnosis and treatment (5except in vitro fertilization), direct access to OB/GYNs, OB/GYNs as primary care providers, depression parity, eating disorder parity
Market Rate Restrictions
NA
Guaranteed Issue Options
NA
Small Group Health Insurance
Below is the guidelines for small group health insurance in the state of California. These regulations apply to all insurance companies offering small group health insurance in California:
Small Group Size
2-50
Employee Qualifications
Must work for at least 6 months out of the year, and work 20 hours per week for coverage
Owner can count as an employee
Guaranteed Issue
Yes
Premium Rating Factors
Rate Bands
Rate Adjustment Factors
10%
Look-Back Period
6 months
Pre-existing condition exclusionary period
6 months
Mandatory Benefits
Same as individual
State Cobra Variations for Small Groups
Below are the COBRA guidelines for small groups in the state of California. For employer groups of more than 20 employees, refer to the federal COBRA guidelines:
Mini-Cobra Option
Yes
Eligible Group Sizes
2-19
Extension of Benefits Period – Standard
36 months
Extension of Benefits Period – Disabled
36 months
Maximum Premium Increase
110% for regular plans and 150% for disability plans
State Legislation Reference
California Insurance Code Section 10128.50 – 10128.59 known as the California Continuation Benefits Replacement Act (5Cal-Cobra)
Additional Notes
Individuals not eligible for Cal-Cobra include those that are eligible for Medicare or have other medical insurance. The Cal-Cobra acceptance deadline is 60 days following the individual’s last day of coverage under the group’s health plan.
Those initially eligible for federal COBRA can extend their coverage to 35 months.
State Sponsored Health Insurance Programs
There are several state sponsored health insurance programs in the State of California to assist those without insurance in obtaining adequate coverage.
High-Risk Pools
Some states offer special state sponsored health insurance plans for qualified persons that are not eligible for individual health insurance due to pre-existing medical conditions. The guidelines for enrollment in these programs vary by state. The high-risk pool in the State of California is summarized in the chart below:
Plan Name
The Major Risk Medical Insurance Program (5MRMIP)
Website
://www.dhcs.ca.gov/Pages/default.aspx
Phone Number
916-324-4695
HIPPA Eligibility Required?
No
Available Carriers
Anthem Blue Cross of California, Blue Shield of California, Contra Costa Health Plan, Kaiser Permanente
Pre-Existing Condition Waiting Period
3 months
Enrollment Periods
Waiting List, enrollment cap of 7,100 members
Premium Limits
Between 125% and 137.5% of standard rate
Lifetime Maximum Benefit
$750,000
Special Notes
Cannot be eligible for both Part A and Part B of Medicare, unless eligible solely because of end-stage renal disease.
Cannot be eligible to purchase any health insurance for continuation of benefits under Cobra or CalCobra
Unable to secure adequate coverage
Children’s Health Insurance Program
Through shared funding from the federal government, the State of California provides health insurance for uninsured children that meet certain eligibility guidelines. A summary of this program is outlined in the chart below:
Program Name
Healthy Families Program
Website
://echealthinsurance.com/california-health-insurance/public-programs/healthy-families-california/
Phone Number
800-880-5305
Apply Online
Yes
Age Limits
Under 19
Insurance Carrier
Anthem Blue Cross of California, Blue Shield of California, Aetna, Kaiser Permanente, Health Net, PacifiCare, United Health Care and Celtic
Length of Coverage
12 months
Residency Requirements
California residents, U.S. citizen, U.S. non-citizen national, eligible qualified immigrant
Other Eligibility Requirements
Not be eligible for no-cost Medi-Cal.
Live in families without health insurance from an employer for the past three months.
Pre-Existing Condition Exclusions
Yes
Cost
Costs $4 to $17 for each child, or no more than $51 for a family. Members also pay a co-payment (5usually $5) when they go to the doctor or get other services. Some services are free.
Medicaid
Medicaid is a state program partially funded through the federal government. Qualification guidelines, as well as the types of people that are eligible, will vary by state. The chart below provides a summary of the Medicaid programs in the State of California:
Governing Agency
Medi-Cal
Website
://www.medi-cal.ca.gov/
Phone Number
800-541-5555
Residency Requirements
California resident
Federal Poverty Line Income Limits
Age < 1: Up to 200% FPL
Ages 1-5: Up to 133% FPL
Ages 6-18: Up to 100% FPL
If you are pregnant, your income can be up to 200% FPL;
Children under 21 in foster care parents: Up to 107% FPL
If you are elderly or disabled, your income can be up to 133% FPL
Additional Resources
California Health Care Options Matrix™ Guide
Provided by the Foundation for Health Coverage Education, the guide is a quick reference guide prepared by the non-profit Foundation for Health Coverage Education that outlines California’s public and private health care choices for individuals and groups with various demographic profiles.
Family Health Insurance Guide by HealthInsuranceFinders.com
The guide created by HealthInsuranceFinders.com provides useful information regarding health insurance coverage such as individual/family health insurance, group health insurance, separate child health insurance and state-sponsored programs that are available for low to middle income families.
California: At-A-Glance
Provides exclusive health data of the California state. Statehealthfacts.org, a project of the Henry J. Kaiser Family Foundation, is designed to provide free, up-to-date, and easy-to-use health data on all 50 states.