Health Insurance in California

Over 2 million Californians live without proper health insurance coverage. Meanwhile the state’s health marketplace and other state’s organizations offer low-cost, subsidized, and frequently free health insurance options to those in need. Speak with a knowledgeable health insurance professional today - to help you secure the optimal coverage to fit your needs.
Here are the most common California health insurance providers:

If you are looking for dental coverage, these are the largest dental insurers operating in California:

If you qualify, you may be able to obtain coverage through a county-based health program.
Local health plans are available in 36 of the 58 California counties. They typically provide coverage to the low income residents and mostly concentrate on the Medicaid programs (Medi-Cal). Two of the plans (L.A. Care and Valley Health Plan) can be purchased on the Covered California Marketplace:

Most health insurance policies cover prescription drugs, preventive services, mental health services, substance abuse disorder services, hospitalization, rehabilitative services, and emergency services. California health insurance policies exclude cosmetic procedures, fertility treatment, weight loss surgery, and sterilization reversal. There are two types of health insurance policies available in California:

• Private insurance
• Public insurance
  Most California medical insurance plans comply with the California Affordable Care Act (ACA). Hence, individuals who purchase health policies will have access to the 10 Essential Health Benefits (EHB) and can get coverage regardless of their health condition. Also, individuals can purchase supplemental health care plans in California to complement their major medical plans.
  Contact a California-licensed insurance agent to buy health insurance. The agent acts as a health insurance consultant and can help you understand how health insurance works in the state and how health insurance plans differ from each other. An insurance expert can help you compare California health insurance quotes from several health insurance companies so you can make the right choice from the several available health coverage options.

How Much is Health Insurance California Per Month?

You can estimate your health insurance costs and subsidies in California by using this calculator (courtesy of the KFF.org, a non-profit):
Note: California Insurance Information Portal does not collect or store any personal information from individuals using this subsidy calculator, which is provided courtesy of the KFF - a national health issues non-profit organization:

How Does Health Insurance Work in California?

Out of the over 1,200 insurance companies doing business in California, as of the end of 2021, 38 of them were licensed by the California Department of Insurance (CDI) to sell health insurance policies. While 7.5% of Californians were uninsured, the remaining insured 92.5% were divided between:

The California medical insurance marketplace is called Covered California (CoveredCA), with over 1.7 million Californians signing up for health coverage in 2022. Health insurance in California is broadly categorized into two, namely:

• Individual market health plan
• Group health plan
  All health insurance policies available in California are required to provide coverage for mental health and substance use disorder. Health insurance companies must provide equal coverage for mental and physical health issues. They cannot limit the number of times a patient can visit a doctor or put a restriction on mental health treatment that outweighs those for other medical benefits. Most health insurance policies in California cover a wide range of basic services, including:
• Hospital care
• Pregnancy and newborn care
• Emergency and urgent care
• Outpatient procedures
• Visits to a primary care doctor and specialists
• Laboratory tests and diagnostic services
• Preventive and routine care
• Mental health care
• Rehabilitation therapy
• Home health or nursing home care after a hospital stay
  Health coverage costs in California vary depending on various factors. Such factors include age, location, gender, marital status, deductibles, and the number of family members covered under the policy. It is the responsibility of the insured to file a health insurance claim when they suffer an accident or illness. To file a claim, you must first obtain an itemized bill that lists the medical services you received and their costs from your doctor. After that, fill out a claim form, which may include personal information, insurance information, out-of-pocket expenses, and healthcare provider information. You can make a copy of your claim form before sending it to your health insurance company. After submitting the claim form, you would have to wait for your insurer to get back to you within the timeframe stated in your policy contract.
  Californians can get health insurance coverage through the following ways depending on their needs:
• Your employer
• The state-run health insurance marketplace (Covered CA)
• A membership association, union, or religious organization
• A California-licensed health insurance agent
• A health insurance company
• The health insurance plan of your parents if you are under 26 years
• Your spouse’s plan
• Student plans offered by colleges or universities
• Children's Health Insurance Program
• U.S. Department of Labor, Employee Benefits Security Administration (for self-insured plans)
  The best way to find affordable health insurance in California is through a licensed health insurance agent or health insurance broker who can help you compare plans from different insurers till you get a policy with low-cost and suitable coverage. Agents are also knowledgeable and skilled in handling health insurance questions and can provide tips on how to get the right coverage.

How Does Group Health Insurance in California Work?

Group health insurance in California is usually called employer-based health coverage because most people get it through their employers. Group health insurance policies are health plans typically bought by employers, unions, or associations on behalf of their employees or members. The insurance policy is issued in the group's name, and the employees only receive certificates of coverage. Group insurance policies sometimes cover employees’ families or dependents and always must comply with the Affordable Care Act (ACA) provisions. The employer may pay some or all of the group health insurance premiums. Group health insurance policies typically provide medical coverage that includes pharmacy benefits, vision services, and dental services.
Any California-based company that employs 50 or more full time employees must offer ACA-compliant health insurance coverage to its employees. Employers do not have to offer health insurance to part-time employees who work less than 30 hours per week.
There are two types of group health insurance in California:

• Large-group policies: These types of health insurance plans are bought by employers with 50 or more employees. Employers or organizations can buy large-group insurance policies directly from health insurance companies in California or through licensed insurance agents in the state
• Small-group policies: These types of health insurance plans are bought by employers with fewer than 50 employees. Employers can get small-group health insurance policies through Covered California
  Employers should discuss with California-licensed health insurance agents who can provide more information on how group health insurance works in the state. Professional agents will compare health insurance quotes from several insurance companies so employers can settle for policies with low costs with suitable health coverage. Additionally, insurance agents get employers flexible group insurance plans where they can freely choose the features of their group coverage.

How Does Individual Health Insurance Work in California?

In California, individual health insurance policies are designed to cover single individuals and family plans cover families. Individuals who do not qualify for employer-sponsored group health insurance can apply for individual health insurance policies through Covered California, licensed insurance agents, or directly from health insurance companies in the state. Only California residents who live in the United States, who are U.S. citizens or nationals (or be lawfully present), and are not incarcerated - qualify to enroll for health coverage through Covered California. All enrollment must be done during the Open Enrollment Period, which is usually between November 1 and January 15. However, you may be eligible to apply through the state’s Marketplace health insurance during the Special Enrollment Period if you have certain qualifying life events.

What Are Alternative Health Plans in California?

Most alternative health plans in California do not comply with the provisions of the Affordable Care Act (ACA). They are not required to meet the same standards of the minimum essential coverage that ACA-compliant health plans cover. As a result, alternative health plans do not have a pre-existing conditions exclusion, meaning coverage is not guaranteed.

Alternative health plans are suitable for healthy people without pre-existing conditions who do not need urgent health coverage. It is also good for individuals who do not require regular health services or prescriptions. California's alternative health plans include:

• Limited benefit plans
• Subscription plans
• Association plans
• Direct primary care
  Discuss with a California-licensed health insurance agent who can help you purchase the right alternative health insurance policy that will suit your health needs.

LIMITED BENEFIT HEALTH PLANS

What are limited benefit plans? In California, limited benefit plans are also referred to as mini-meds or simply as a limited medical plan. They offer restricted benefits than traditional health insurance policies but typically come with lower premiums. A Limited benefit health plan should not be a person's only health coverage, but it can be used to supplement standard health policies. Common limited-benefit plans in California include:

• Fixed indemnity plan: It is a type of supplemental coverage that pays a specific amount for each medical treatment, service, or event regardless of the actual cost of the medical care
• Critical illness plan: It provides additional coverage for medical emergencies like cancer, coronary bypass, heart attacks, organ transplant, or strokes. Critical illness plans typically come at low costs, but the coverage is limited to a few illnesses
• Hospital indemnity plan: It pays for hospitalization costs and/or helps offset the high deductible of the main health insurance policy in case of a hospitalization
• Basic surgical expense: It covers the costs of operations or medical procedures regardless of whether the surgery was done on an inpatient or outpatient basis
• Accident-only plans: These are supplemental insurance policies that cover certain types of medical care needed after an accident
• Basic hospital expense: It covers essential hospital costs for a given period. Basic hospital expense plan pays for X-rays, IVs, drugs, lab fees, and anesthesia
• Accidental death and dismemberment: It offers financial help when an insured dies or loses a body part due to an accident
• Disease-only plan: The plan covers an insured when they are diagnosed with certain diseases

Generally, limited-benefit health plans benefit individuals who need additional coverage beyond their traditional health insurance policies. A limited medical plan may be a good fit for people who:

• Do not have access to employer-sponsored coverage
• Are no longer eligible to be under their parents’ coverages
• Recently lost their jobs
• Are in-between jobs
• Cannot afford comprehensive medical coverage
• Recently lost their medical coverage
• Were unable to enroll through Covered California during Open enrollment
• Cannot afford to offset out-of-pocket medical expenses
  To learn more about limited benefit plans in California, speak with a state-licensed health insurance agent who has access to multiple insurers offering limited medical plan options.

SUBSCRIPTION HEALTH PLANS

Subscription healthcare plans are supplemental health coverages that allow a member to pay a monthly, quarterly, or annual fee to use a physician or service covered in the plan. Note that the number of doctor visits can be limited. A member of a subscription health plan must carry their membership ID when seeing a doctor. The two major subscription health plans available in California are:

• Concierge Medicine
• Direct Primary Care
  Direct primary care (DPC) allows clients or patients to pay their doctors directly periodically for defined sets of primary care services. Alternatively, concierge medicine is a membership-based healthcare plan that offers unlimited office and telehealth virtual visits and direct care from a doctor in exchange for a flat monthly fee.

DISCOUNT HEALTH PLANS

Technically, discount health insurance plans are not health insurance plans. Instead, they offer discounts to a member for medical services and issue an ID to them for that purpose. A typical discount health plan is much less expensive than health insurance but does not provide similar coverages as a health insurance policy. A discount health plan is not a substitute for standard health care coverage. Instead, they give individuals access to healthcare providers offering discounts on some of their health care services or products. Most licensed health insurance companies in California do not offer health insurance deals, except for specialized services like prescription discounts. Discount health plans are for individuals without health insurance policies either because they are not eligible, their employer did not provide group coverage, or they can not afford health coverage. Before you enroll in any discount health plan that promises to provide a discount for insurance, speak to a California-licensed health insurance agent who can determine if discount health plans are good for you. Instead of settling for a discount health plan, an agent may be able to find you an insurer that offers affordable health coverage that suits your needs and financial capacity. Alternatively, if you are not purchasing health insurance due to affordability, ask the agent how you can qualify for government subsidies, to significantly lower the cost of health insurance or get it nearly for free.

ASSOCIATION HEALTH PLANS

Association health plans in California are flexible group insurance plans where multiple small companies come together under one coverage to access medical care benefits available to large group companies. This plan allows associations to negotiate better insurance rates with their insurance companies and pay lesser health insurance premiums. Association health plans are designed for small business owners, associations, sole proprietors, and self-employed persons.
If you are a small business owner looking to offer your employees cheaper group health insurance coverage, speak with a California-licensed health insurance agent or a broker, to discuss the possibility of joining an association.

DIRECT PRIMARY CARE

What is direct primary care? Direct primary care (DPC), also known as Doctors Direct Healthcare (DDH), is an alternative health plan that provides patients with unlimited access to a specific set of primary personal physician care services in exchange for a monthly membership fee. The DPC model provides its members access to an affordable doctor without insurance.
These primary care membership services include comprehensive primary and urgent care, such as the extended visits, telemedicine, comprehensive care management, lab, and consultative services, clinical and laboratory services, and care coordination. To enjoy DPC benefits, a member must use their member ID card when visiting their primary care provider. In California, direct primary care is good for the following persons:

• People who travel a lot
• Elderly patients who can not visit the doctor
• Families with small children
• People with severe medical issues
• People who need specialized care
• Healthy people who need to see a doctor for routine visits or short-term health issues
  For more information on how direct primary care membership works and how to get one, talk to a California-licensed insurance agent in your locality.

TELEHEALTH and TELEMEDICINE

California telehealth involves physicians’ use of digital information and communication technologies to ensure patients have remote access to healthcare services. These include using computers and mobile devices like smartphones and tablets.
Why is telehealth important? Telehealth model allows the subscribers to use virtual medical visits. The medical appointment to be conducted from home, a hospital, or a mobile van (usually in rural areas). Telehealth can be a part of a benefit of a major health ACA insurance policy or purchased as a stand alone or supplementary subscription. The objectives of telehealth in California are:

• To make healthcare services easily accessible to individuals who live in remote communities
• To keep other people safe from patients with infectious disease
• To provide primary care for medical conditions like bronchitis, migraines, diabetes, high blood pressure, asthma, and gastroesophageal reflux disease (GERD)
• To ensure people with mobility issues and busy schedules have easy access to health care
• To ensure people have sufficient access to medical specialists regardless of the location
• To close the communication gap between healthcare providers and patients
• To offer advice for self-management of health care
  The benefit of telemedicine is the use of technology to deliver health care to a patient at a distance. Telehealth is different from telemedicine in that it offers broader remote healthcare services than telemedicine. Telemedicine typically provides access to a remote clinic, while telehealth also offers remote non-clinical services in addition to clinical services. Telehealth and telemedicine can be particularly a useful for some demographic groups, including:
• Delivery truck drivers
• Pregnant women
• Non-English speakers
• People battling mental issues
• People with limited physical mobility
• People with temporary acute medical problems
• People with ongoing chronic health conditions
• People who reside in remote areas with limited access to medical care
• People who need to see a specialist but do not have one in their locality
• Caregivers for children or old adults
  Discuss your telehealth questions with a licensed California health insurance agent.

HOSPITAL AT HOME

Hospital-at-home, also known as the Hospital-in-House, is a care delivery model that allows a patient who needs acute care in the comfort of their home and not in a hospital. Typically it used to transition a recovering patient home after hospitalization. This system helps to reduce costs, improve outcomes, and enhance the patient's experience, while providing the inpatient level of care.
According to the Johns Hopkins’ Hospital at Home program study, transitioning home after hospitalization can save 19% to 30% compared to the costs of nursing care delivered in a hospital, in a traditional inpatient care setting.
Hospital at home is a useful option for older adults, people with mobility issues, and those needing post-op care in California.

SHORT-TERM LIMITED-DURATION HEALTH INSURANCE

Short term health insurance enrollment is not available in California.
California temporary medical insurance: In 2019, health insurance companies offering health insurance to the residents of California were banned from issuing, selling, amending, renewing, or offering short-term major medical insurance policies.

What Are Additional or Stand-Alone Health Insurance Options in California?

Additional or stand-alone health insurance options are supplemental health plans that help individuals pay for healthcare coverage costs not covered by standard health insurance plans. These costs include copayments, deductibles, and coinsurance. There are many additional or stand-alone health insurance options in California, such as:

• Vision plans
• Dental insurance
• Hospital indemnity
• Disability income insurance
• Long-term care insurance
• Medicare supplemental plans
• Accidental death and dismemberment (AD&D) insurance

Contact a California-licensed insurance agent who can help you go over your health insurance needs and recommend the best additional or stand-alone health insurance policy to supplement your standard health insurance policy. They can also help you compare stand-alone health insurance quotes from multiple insurance companies to get an affordable policy that can adequately supplement your standard health policy.

Does Health Insurance in California Cover Medical Cannabis?

No. According to the federal law, cannabis is a Schedule 1 substance, which makes it illegal to possess, even though on a state-level California medical cannabis is legal. Insurance by default cannot insure anything illegal. In order to get insurance to cover medical cannabis, it must be decriminalized or rescheduled to a lower schedule tier. Once that happens on the federal level, medical cannabis patients would be able to use health insurance and health savings accounts (HSA) to buy their weed.

What Health Insurance Rights Do I Have in California?

There are certain health insurance rights you have in California that you should know if you have or plan to purchase health insurance coverage. You have the right to:

• Get quality health care
• Understand your health challenges
• Get an interpreter while trying to get health coverage if English is not your first language
• Be treated with courtesy and respect
• Get an appointment when you need one
• Get care from qualified medical personnel
• Obtain copies of your medical records
• Receive or decline medical treatments
• Make your health information confidential
• Get a second doctor's opinion about treatment or diagnosis
• Understand the benefits and risks of your treatment choices
• Choose a primary care doctor or pediatrician you trust, and change doctors if you are unsatisfied

You can file a complaint with the California Department of Insurance if you have a problem with your health insurance company or your policy. Also, you can ask for an independent medical review if your insurance company denies, modifies, or delays your healthcare services. Individuals under managed care plans can read about their Health Care Rights. Alternatively, speak to a California-licensed insurance agent who can explain your rights to you and ensure your insurance company does not cross the lines.