California Health Insurance Plan Questions

General FAQs

A. The level of benefits and the amount of freedom to choose among physicians and hospitals are usually the two main differences. Benefits are also a key difference deductible, co-insurance, co-pays and networks. See below . . .

HMO: Health Maintenance Organization provides very rich benefits - preventive care coverage and low out-of-pocket costs. There is typically no coverage for care from doctors or hospitals outside your HMO plan. Unless you have a Point of Service option or except in an emergency. HMO plans usually offer comprehensive benefits, affordable premiums with no deductibles and minimal cost- sharing. PCP or Primary Care Physician that you select from within the network oversees all your care. Unless you have a direct access feature in your plan - your Primary Care Physician will coordinate referrals to specialists when necessary.
PPO: Preferred Provider Organization is a network of physicians and hospitals that have agreed, by contract, to discount their rates to members. The networks are typically very large, and the members are free to seek care from any physician or provider within the network. Including specialists without a referral. Members may also access non-contracted providers, but at a higher out-of-pocket cost, this is called out of network benefit. PPO plans consumers usually have deductibles, co-pays, prescription benefits, and co-insurance.

Q. Who is eligible to join an Individual Plan?

A. Any individual who is not eligible for Medicare may apply. With most plans, children can even be signed up independently. Individual plans can save some consumers some money. For example, your spouse has group coverage, but to sign their spouse up premiums are high. Apply for an individual policy and save money. See specific plan for details.

Q. What about pre-existing conditions?

A. Pre-existing condition limitations vary from plan to plan. Please refer to the plans limitation and exclusions for more detailed information. Most plans only go back 12 months on pre-existing. After this waiting period most insurance companies might start to cover your condition.

Q. Maternity coverage with a PPO?

A. Again this will vary from plan to plan. In many plans, maternity coverage might be an option, and in others it may be included. Generally, HMO individual plans will typically offer better and more affordable maternity coverage than PPO individual plans. Most PPO plans have a waiting period before any benefits will be awarded. Most waiting periods are 12 months.

Q. What is a Primary Care Physician?

A. A Primary Care Physician is trained to manage you entire health care program. Primary Care Physicians typically include Family/General Practitioners, Internists, and Pediatricians. If you choose an HMO plan, you will usually be required to select a PCP from the available network. With a PPO plan, you usually are not required to select a PCP. You are available to visit any physician within the network. Online Provider Directories are available from your insurance company this site can also assist you in searching for physicians and/or hospitals.

Q. What about claim forms?

A. With a HMO or PPO, there are virtually no claim forms to complete. When you visit your physician's office or other health care provider in-network, you will typically show them your Plan Identification Card and they will handle the rest.

Q. How long does the application process take?

A. This will vary depending on the plan you select, however on average you usually will hear back within two to three weeks. The process could take longer sometimes, if additional information and/or medical records are requested. Be very detailed on your application form this will help the process. You may want to take out a short-term policy for 30 days.

Q. When will my coverage take effect?

A. Unlike some other types of insurance, health insurance cannot be bound for coverage immediately. Your application for coverage will go through an underwriting process and does need to be approved by the insurance company you are applying with. With some plans, coverage can only be started on the 1st of the month - with others you may be able to specify a requested effective date on or after the date you sign your application. You are only covered when you receive a policy from your insurance company.

Q. What about health insurance for few months?

A. If you need temporary insurance for a short period of time you may want to consider Short-Term Coverage. This type of coverage is generally easier to apply for, quicker to process, and also less expensive than permanent coverage. This policy does not cover any pre-existing. This is a non-renewable policy and is applied for with one premium payment for the term you select.