Health Insurance Options in California

In 2006 The Centers for Disease Control released a study showing (Reference 1) 43.6 million Americans have no health insurance. This staggering number included 9.3 million children. As of 2010, President Obama and the United States Congress began to make it possible for all Americans to have health insurance. In 2010, California had 3 major forms of insurance available, along with self employment insurance and 2 state funded programs.

Indemnity Policies

• A traditional indemnity policy, according to California law, is the simplest form of health insurance. This policy allows you to see any doctor or hospital and after paying the deductible amount listed in the policy (often called the co-payment) the health insurance company will pay out a percentage of the remaining bill. Whatever the health insurance company does not pay is left to the patient.

  Indemnity Policies include in their policies documentation what procedures are covered, when you sign up. The California Department of Insurance (CDI) regulates indemnity policies. All complaints about the company or their policies are handled by the CDI.

Preferred Provider Organization

• A Preferred Provider Organization (PPO) is a cross between a traditional indemnity policy and a Health Maintenance Organization. PPOs will give you a list of preferred providers but does cover any the fees from any doctor. PPOs have a lower co-payment and pay a higher percentage of the bill if you use one of their preferred providers. Anyone outside of their network of preferred providers will cost the patient more.

  If you have a PPO through Blue Cross of California or Blue Shield of California, your policy is regulated by The California Department of Managed Care (CDMC). Other PPO programs are covered by CDI.

Health Managed Organizations

• Health Managed Organizations (HMO) only cover those doctors and hospitals that are part of their network. They usually give you many options in the area to choose from, but if you go to someone who is not part of their network, they will not cover any expense.

  HMOs have a co-payment and pay only a portion of the total bill. HMOs are assigned by geographic regions and usually only cover doctors and hospitals in the area. California law states that HMOs must cover emergency services even if you are not in the their coverage area during the occurrence.

  HMOs are regulated by the CDMC. If you have a complaint, start with the HMO's customer service system before going to the CDMC.

Self Employment Insurance

• Self Employment Plans (SEP) are used by major groups like labor unions and school districts. The individuals pay dues or other membership fees. Part of these funds are used to pay for the group's health insurance plan, using a third party to manage the funds and coverage.

  With the exception of school districts, other municipalities and churches, the U.S. Department of Labor, Employee Benefits Security Administration regulates self employment plans. School Districts, other municipalities and churches do not have any regulations and you must contact the plan directly with complaints.

State Funded Programs

• California has two state funded programs for low income citizens. Both are run by the Department of Healthcare Services.

  Medi-Cal is a state funded program to help anyone with low income. Fees are charged on a sliding scale, dependent on your income. Medi-Cal uses an HMO style system to manage it's health care but covers all expenses including co-payments after the original fee is met. To apply or to find out more information, you can go to your local county administration offices.

  Access for Infants and Mothers (AIM) and Healthy Families are for pregnant women and children under 18 whose income is to high for Medi-Cal but do not have health insurance. Both AIM and Healthy Families work with HMOs to cover patients. A monthly fee is charged, based on income. This fee is significantly less than an average HMO plan. AIM and Healthy Families cover any bills not covered by the HMO.