Frequently Asked Questions
Under the Affordable Care Act, all plans must cover a comprehensive package of items and services known as Essential Health Benefits:
- Ambulatory patient services (outpatient service)
- Emergency services
- Hospitalization
- Pregnancy, maternity, and newborn care
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions, to gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness servicesand chronic disease management
- Pediatric services, including oral and vision care (adult dental and vision coverage are not essential health benefits)
Open enrollment is a period that allows you to apply, cancel or change your health insurance plan for the following year. It usually starts in November and ends in January of the following year.
Special Enrollment Period allows you to apply for health plan outside the Open Enrollment Period if you experience a qualifying life event. The application must be received within 60 days (about 2 months) after the qualifying event.
- Loss of health care coverage
- Birth, adoption, or placement for adoption
- Become a permanent resident of California
- Loss of essential coverage due to change in employment status
- Loss of Dependent Child Status
- Release from incarceration
- Change in immigration status
- Return from active military service
- Marriage, divorce, or legal separation
- Others
| HMO | EPO | PPO | |
|---|---|---|---|
| Primary Care Physician (PCP) required? | Yes | No | No |
| Referral to see a specialist. | Yes | No | No |
| Network limitations | Only within 15-30 Miles or residence | Limitation of radius from residential address | No limitations |
| Out-of-Network coverage? | No | No | Partial (highly recommended to choose an in-network provider) |
| Flexibility | Low | Medium | High |
| Bronze | Silver | Gold | Platinum | |
|---|---|---|---|---|
| Monthly Cost | $ | $$ | $$$ | $$$$ |
| Percent of cost Coverage | 60% | 70% | 80% | 90% |
| Consider this tier if you… | Lower medical needs. Lower premium, higher out-of-pocket. |
Average medical needs. Lower monthly premium, higher out-of-pocket. |
Higher medical needs. Higher premium, higher out-of-pocket. |
Often medical needs; highest premium, lowest out-of-pocket. |
The amount you pay for health care services that your health insurance or plan covers before your health insurance or plan starts paying.
The fixed amount you pay for a covered health care service, usually at the time you receive the service. The amount may vary based on the type of covered health service.
Medi-Cal offers free or low-cost health coverage to eligible California residents with limited incomes. Covered California is the state’s health insurance marketplace. Californians can shop for health insurance plans and access financial assistance if their household income is within the subsidy range.
The charges for Urgent Care will usually be the same as visiting a family doctor in most plans.
Patients will receive a high amount of medical bills even if the patient only got a regular checkup in ER.
| Urgent Care | Emergency Room | |
| Cost | Lower | Higher |
| Wait Time | You will usually be in under 30 minutes | Average wait time is more than 2 hours. |
| Open | Extended hours open during weekends | Open 24/7 |
Things to know while shopping for insurance
Californians may receive premium assistance if they are eligible and apply through Covered California.
With low fees and an easy application process, travel insurance is a good choice for this. This covers the insured should there be a need for medical attention while travelling. Please keep in mind, however, travel insurance does not cover medical expenses incurred due to any pre-existing conditions.
With low fees and an easy application process, travel insurance is a good choice for this. This covers the insured should there be a need for medical attention while travelling. Please keep in mind, however, that travel insurance does not cover medical expenses incurred due to any pre-existing condition.
Q：What kind of insurance is most useful for extended stays abroad, such as students studying abroad?
Not necessarily. Different plans cover different things, it is better to choose plans based on your personal medical needs, and that of your family.
You should choose appropriate plans based on your own medical needs—if you tend to have many doctor visits, you should choose a plan with low copay to lower your bills. If you need to have surgeries or hospital stays, then choose plans with low deductible, such as gold or platinum plans, to help lower medical fees.
Under HMO plans, you must choose your own Primary Care Physician. From your insurer’s website, you can find doctors who are in-network, then filter by distance, language, gender, etc. Make sure you choose doctors who are accepting new patients.
Here are some common insurance websites for finding in-network doctors:
Things to Know After You are Insured
If you provide the insured’s name, birthdate, and social security number, the doctor’s office can obtain the details from the insurance company. It is highly recommended to create an account with your insurer, either through their website, or with their smartphone app, after the effective date of your coverage has started. This way, you can obtain your insurance information digitally even if you forget your insurance card.
Through the web – From your insurance company’s website, create an account using your insurance information, and you will be able to pay through their website.
Through the phone – If you call the customer service number on your insurance card, you can follow the steps or speak to a representative to pay.
By check – After receiving your bill through the mail, you can write a check and mail it back to your insurance company.
Automated – During the application process, you can ask your insurance agent to set up automatic payment so that the premiums are automatically deducted from your account.
Most insurance companies have a 30-day grace period if you forget to pay your premiums on the first of the month. If you pay off all the fees before the end of the month, your coverage will not be affected. If you have not paid after the grace period, then the insurance company may choose to terminate your coverage, so please avoid delinquent payments.
Insurance companies will provide compensation 60 to 90 days (about 3 months) after a claim is filed for medical expenses if they have validated the claim.
A cancellation request must be filed prior to the 15th of the month. After receiving the request, it will take 7 to 10 business days for the policy to be canceled starting next month. In other words, if you want to cancel a policy starting on 7/1, you must file the request before 6/15.
