About Individual Health Insurance in California

Individual health insurance in California is regulated by the state insurance commissioner under the provisions of the California Insurance Code. The state has several avenues by which a person can get individual health insurance, either via a private carrier or a state program such as Medi-Cal, COBRA, Cal-COBRA, HIPAA or the state risk pool.

Private Insurance

• The most widely known type of individual health insurance is through a private insurance carrier. In California the most popular carriers are Blue Cross and Blue Shield. While in some states the two companies are synonymous, in California they are separate entities. Both are popular because they have large provider networks and are accepted by most doctors. In California, having a carrier with a large network of doctors is very important because the state contains lots of remote areas far away from large cities. To obtain private insurance, though, you have to be in just about tip-top shape as the insurance companies underwrite their risk pool. What this means is that if you take any medications, have weight issues, are pregnant or had a recent hospital visit, you may be denied coverage. Still, if you manage to make it through underwriting, private insurance usually carries the cheapest premium.

Managed Medical Risk Pool

• Through its medical risk pool, California helps provide insurance to people whom private carriers may deem "uninsurable." The program has several subprograms, the most prominent being Access for Infants and Mothers (AIM). To qualify for AIM, a woman must be less than 30 weeks pregnant, not be on Medi-Cal or Medicare, and either be uncovered by private insurance or have a high maternity deductible. Applicants must also meet certain income requirements. The program costs 1.5 percent of the applicant's adjusted monthly income.

  A second program is the Healthy Families Program, which is essentially an extension of AIM. Healthy Families provides health, dental and vision insurance at a low premium for children who are uninsured or live in low-income families. The application requirements are similar to those of AIM, as the family must meet certain income requirements and not be on Medicare or Medi-Cal.

  Finally, there is the Major Risk Medical Insurance Program, funded with money raised by the state's tobacco tax. The program is very expensive and may have a waiting list, but it provides a last resort for people with pre-existing conditions who cannot obtain private insurance coverage.

Medi-Cal

• Medi-Cal is California's version of what is known in other states as Medicaid. This is a program designed to provide health care coverage to low-income families and individuals. The program is funded by both the state and federal government. You can get Medi-Cal if you are enrolled in a state assistance program, are 65 or older, pregnant, disabled, in a nursing home, a refugee, or are the guardian of a child whose parents are incapacitated, deceased or unemployed. The program is free to those that meet requirements and provides basic health care services.

COBRA and Cal-COBRA

• COBRA and Cal-COBRA are both plans for employees who wish to continue their work insurance after leaving their job. COBRA, funded by the federal government, is the plan you go on when you leave your job. After 18 months, if you wish to continue the insurance, you can sign up for Cal-COBRA for another 18 months. Cal-COBRA is California's version of the federal COBRA law. Under the recent American Reinvestment and Recovery Act of 2009, you can get your Cal-COBRA premium lowered if your employer allows it. You have 60 days from receipt of your notice of eligibility to sign up for COBRA/Cal-COBRA. The upside to doing COBRA/Cal-COBRA is that the benefits remain the same as you had at your job. The downside is that the plan tends to be expensive.

HIPAA

• The Health Insurance Portability and Accountability Act, or HIPAA, is usually the absolute last line of defense when it comes to health insurance in California. HIPAA allows you to buy individual health insurance when you have exhausted your group health insurance options and cannot get private insurance because of pre-existing conditions. The benefit to HIPAA is that you cannot be denied for any pre-existing conditions. However, there are several drawbacks. First and foremost, the plan is expensive. Second, the eligibility requirements can be restrictive. To be eligible for HIPAA you must have had health insurance during the past 18 months and have exhausted your COBRA and Cal-COBRA eligibility. You cannot have other health insurance and you cannot have lost your previous health insurance due to a failure to pay premiums. HIPAA plans do tend to be very good plans through good carriers such as Blue Cross and Kaiser Permanente, but the plans vary, and again, the costs are high.