The new Covered California health insurance marketplace offers a wide range of affordable health plans for you to choose from. Whether you are self-employed, or looking for coverage over and above what your employer currently offers, there is a plan that will likely meet your needs. Federal regulations require that health plans operating under the Affordable Care Act (ACA) meet certain access requirements. In California, those requirements include timely access to healthcare providers, as well as geographic access standards.
Here is a general guide to individual health insurance that you can refer to when choosing a plan. And do not forget these important dates regarding open enrollment for 2016.
When selecting a health insurance plan, it is important to verify the plan’s provider network of doctors, hospitals, nurse practitioners, therapists, and other health care providers. It is equally important to understand what is not covered as well. Understanding your plan’s provider network helps you save money, receive better care, avoid unexpected fees and costs, and be happier with the care you receive.
You are not restricted to health care providers in your network, but should you decide to use one outside of your network, health insurance will cover less resulting in a higher out-of-pocket cost for you, except in the case of emergencies.
Provider No Longer in Network
If your health care provider leaves your network, you will generally need to find a new doctor inside the network, and most plans will assist you in doing so. As a rule, a health plan’s continuity of care policy allows a patient to continue care with a doctor no longer in the network for a certain period of time at the lower cost-sharing rate.
Each plan has different cost-sharing requirements. Typically, your overall share of costs is a combination of the premiums you pay plus any other co-payments, co-insurance or deductibles for which you are financially responsible.
How to Find a Doctor
In most cases, the plan you choose will have a list of doctors who accept your insurance. The Medical Board of California offers some great tips on choosing a doctor:
- Ask friends, family or co-workers about physicians they like.
- Ask your county medical society or association for names of physicians in your area.
- Once you have some names, call and ask if the doctor is accepting new patients and whether they accept your insurance plan.
- Check with the Medical Board to verify the physician has a current California license.
- Meet with the physician and consider having a physical done to determine if this is the doctor for you and your family.
Selecting a Hospital
When you undergo treatment in a hospital or other facility, ask to have any services performed by in-network providers. Your physician may decide which hospital is appropriate for your care, but you can still check the hospital’s California HealthCare Foundation rating by visiting www.calqualitycare.org.
This guide to individual health insurance is far from complete. For more information and a more comprehensive glossary of insurance terms and other marketplace information, visit www.healthcare.gov.
From preventative services to out-of-pocket maximums, understanding your individual health insurance plan options can be a confusing – and frustrating – endeavor. A health insurance agent is one of your best resources for information on coverage that meets your unique needs.