Resources
FAQs
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General Health Insurance
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All plans offered in the Marketplace cover these 10 essential health benefits:
Ambulatory patient services (outpatient care you get without being admitted to a hospital)
Emergency services
Hospitalization (like surgery and overnight stays)
Pregnancy, maternity, and newborn care (both before and after birth)
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, gain or recover mental and physical skills)
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care (note: adult dental and vision coverage aren’t essential health benefits)
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Plans ordinarily cover other services as well as the mandatory coverage outlined above. We will show you the benefits of plans being offered and guide you through the selection of the plan that fits your healthcare requirements and your budget.
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Generally, yes. Most healthcare plans have deductibles, copayments, and other out-of-pocket costs that apply to most covered services. Some preventive services are free, and some plans cover other services without out-of-pocket costs.
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The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
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A copay is a fixed out-of-pocket amount paid by an insured for covered services. It is a standard part of many health insurance plans. Insurance providers often charge co-pays for services such as doctor visits or prescription drugs. Copays are a specified dollar amount rather than a percentage of the bill, and payment is usually required at the time of service. Not all medical services require a copay. For example, some insurance companies do not require a copay for annual physicals.
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The percentage of costs of a covered health care service you pay after you've paid your deductible. For example; Your plan pays 80% of a claim and you pay 20% of the total cost of the claims. Common coinsurance amounts are 20%, 30%, 40%. Generally speaking, plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance. Not all plan types have a coinsurance payment.
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An explanation of benefits (EOB) is a form or document provided to you by your insurance company after you had a healthcare service for which a claim was submitted to your insurance plan. Your EOB gives you information about how an insurance claim from a health provider (such as a doctor or hospital) was paid on your behalf—if applicable—and how much you're responsible for paying yourself.
Individuals & Families FAQs
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California was the first state to authorize a state-run exchange under the Affordable Care Act. Covered California is widely regarded as one of the most successful state exchanges established under the Affordable Care Act.
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Health Insurance Benefits are the services your health insurance pays for:
• To use a benefit, you must need it
• Your health insurance only pays for services that are medically necessary
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The State of California requires you to have health coverage that meets certain minimum essential coverage requirements; qualify for an exemption. If you do not have health coverage, you will pay a penalty when you file your taxes. Always confirm your circumstances with your tax advisor.
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Your insurance company must provide you with a Summary of Benefits (we provide and review them with you as well).
• Understand your Insurance policy and how it works (we will make sure you have a copy of your policy and go over all details with you). This has more information about your costs and benefits. It also tells you the services that are not covered.
• Call with questions!
• Most health insurance companies have a policyholder services phone number you can call with questions.
• Ask us first! We can answer most of your questions and help get answers for those we cannot. CLICK HERE to book a quick phone call or Zoom meeting with us.
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You may be surprised! Individuals and families may qualify for the Medi-Cal program and subsidies from the federal government toward the purchase of a private insurance plan. Recent federal/state programs have expanded the extent of aid available, and all opportunities should be explored before assuming healthcare is unaffordable.
Seniors Medicare FAQs
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Original Medicare, the government-run health insurance option, works on a fee-for-service basis. This means that you can go to any doctor or hospital that accepts Medicare, anywhere in the United States, and Medicare will pay its share of the bill for any Medicare-covered service provided. You pay the rest unless you have additional insurance that covers those costs. Original Medicare provides many health care services and supplies, but it often does not pay all your expenses.
Seniors can choose Original Medicare (Parts A and B) on their own, with the option to add Part D prescription drug coverage. You can get prescription drug coverage by joining a private Part D drug plan for an additional premium, and you can also choose to buy private supplemental insurance (known as Medigap) to cover some of your out-of-pocket costs in the original program.
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Medicare Advantage plans are Medicare health insurance plans sold by private insurance companies. These plans are a popular health insurance option because it works like private health insurance for Medicare beneficiaries. In addition to covering all original Medicare services, most Medicare Advantage plans offer prescription drug, dental, vision, hearing, and other optional coverage.
Medicare Advantage plan costs vary depending on the plan you’re enrolled in, your location, your medical needs, and more.
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The amount you pay depends on your modified adjusted gross income from your most recent federal tax return. Medicare beneficiaries with incomes above $85,000 for individuals and $170,000 for married couples are required to pay higher premiums
To determine your income-related premium, Social Security will use information from your tax return filed in the previous tax year. If your income has gone down since you filed your tax return, you should contact Social Security and provide documentation regarding this change
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We highly recommend them as a means to ensure your current coverage serves your needs and requirements. Let’s say an “annual wellness check” of your satisfaction with your current plan and/or a desire to see what else is available.
Private Medicare plan providers are competitive. Generally speaking, greater competition among private Medicare plan providers is seen as beneficial to consumers and purchasers, in terms of controlling costs and promoting quality.
When can I enroll in/make changes to my Medicare Plan?
Initial Coverage Enrollment Period (ICEP)
All Year
7-month period that starts 3 months before and ends 3 months after the month of your 65th birthday
Annual Election Period (AEP)
Oct. 15th to
Dec. 7th
If you are eligible, you can enroll in Medicare health benefits (e.g., a Medicare Advantage Plan, with or without prescription drug coverage, or you can enroll in a stand-alone Prescription Drug Plan)
Special Enrollment Period (SEP)
All year
You may qualify to make plans changes based on special circumstances (e.g., you move, specific chronic conditions, or you qualify or lose Medicaid)
Open Enrollment Period (OEP)
Jan. 1st to
Mar. 31st
Medicare Advantage plan members can make a one-time election to switch Medicare Advantage plans or disenroll from their current Medicare Advantage plan and return to Original Medicare
Small Business FAQs
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Premiums are generally deducted on a pre-tax basis. Once enrollment has been concluded you will receive a deduction summary for payroll processing. At the end of each month, you get one consolidated monthly bill, one point of contact, and one website where you can manage your benefits.
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Insurance companies determine how much they will increase premium rates across the pool of small group companies. Each insurance company has autonomy in determining how much they will increase rates, but they must apply the same increases to all small group health plans.
Small group increases depend on a variety of demographics, such as the following for example:
• The age of your employees
• The home zip code of your employees
• The specific group health plan you enroll in
• Increases in actual health care costs
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Generally speaking, the answer is no. For this reason, we encourage periodic and annual strategy meetings in advance of renewal to prepare for foreseeable increases and identify the means to mitigate/offset them as below.
Means to mitigate/offset increases
The following are examples of mitigation strategies:
• Can we reduce premiums by using a different provider network
• Could we change group health insurance products
• Should you switch carriers
• Can we select higher deductibles and/or copays and offset increased out of pocket with low-cost supplemental insurance
• Can we change employee behaviors by encouraging:
• The use of telemedicine
• Urgent care v. emergency room when practical
• Providing resources to help employees develop a wellness strategy and manage chronic conditions
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If an employee does not receive a paycheck, the employer has no means to deduct his/her share of the monthly premium payment. It is important to address the solution and manner that an employee’s contribution will be made before a leave of absence occurs. Many employers include a strategy for the payment of the employee’s share of the premium in their employee handbook, which commonly includes a signature affirming receipt of such handbook. We encourage you to discuss this topic with your legal advisor proactively rather than reactively.
