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CA Department of Insurance

Overview: Healthcare Coverage in California

There are many types healthcare coverage in California. Health insurance, Health Plans (HMOs), and public programs like MediCare and Medi-Cal are all different. They each follow their own set of rules. Different government agencies regulate each one. We have put together this list of healthcare coverage options, descriptions, and the agency that regulates each one. These regulators can help you if you have a question or a complaint.

Health Insurance Policies

Health Insurance gives you coverage if you need medical care or are in the hospital. Your insurance policy explains in writing what is and what is not covered. Consumers can buy health insurance policies as either "Group" or "Individual/Family" policies.

Group Policies are purchased by your employer or an association (such as AARP). The policy is issued in the name of the group and Certificates of Coverage are issued to the group members (employees). You may be able to add family members or dependents on your policy and your employer may require you to pay for some or all of the monthly premium.

An Individual/Family Policy is insurance you buy outside of an employer or association. The policy is issued to the individual who applies for it and their family. More information about shopping for health insurance is available. Once you have an individual/family policy, you can add other family members and dependents in some cases.

Insurance is subject to the laws in the State where the policy is issued. In California, insurance is regulated by us, the California Department of Insurance.

Health Maintenance Organizations (HMOs) and Managed Care Plans

This kind of health coverage is different from traditional insurance policies and is governed by a different set of laws in California. See our Types of Health Coverages page for more detail about HMOs and managed care plans and how they differ from health insurance policies.

As with health insurance policies, health plans can be purchased either as "group" or "Individual/Family" plans.

HMOs and Managed Care Plans are regulated by the California Department of Managed Health Care (DMHC). For a complete list of Managed Care Plans in California, please visit the DMHC web site.

NOTE: Medicare Advantage/HMO plans are not directly regulated by the Department of Managed Health Care. These plans are regulated by the federal government through the Centers for Medicare and Medicaid Services (CMS). For more information about Medicare Advantage/HMO plans, visit their Medicare Advantage Plan web page or call them directly at 1-800-633-4227.

Self Insured Health Plans

Many large employers are self-insured. A self-insured employer has a large pool of money and uses it to pay for the health care of employees. The employer most often contracts with insurance companies to manage the health benefits.

It is important to know if your employer is self-insured! Why? You may not have the same protections and benefits as other types of coverage. Self-insured plans do not have to follow California laws on essential health benefits, complaints, and coverage.

Self-insured plans issued by private (non-public) companies follow the Federal Employee Retirement Income Security Act of 1974 (ERISA) and are regulated by the U.S. Department of Labor, Employee Benefits Security Administration (EBSA). Visit the EBSA's Consumer Assistance page for more information or call them at 1-866-444-3272.

Medi-Cal

Medi-Cal is California's version of the federal Medicaid program. This program generally covers lower-income families and single adults. Medi-Cal is mostly provided by Managed Care Organizations and covers an array of medical procedures, office visits, and other health-related expenses. You do not pay for Medi-Cal. Instead, you receive it as a benefit if you qualify for it. In 2014, Med-Cal was expanded to include more Californians, including single adults.Visit our Public Programs page for more information on Medi-Cal. You can also visit the California Department of Health Care Services web site, call their Medi-Cal Hotline at 1-800-541-5555, and/or visit their Medi-Cal Frequently Asked Questions page.

Access for Infants and Mothers (AIM)

The program is mainly for low-income pregnant women and their infants who do not have health coverage and do not qualify for Medi-Cal or MediCare Parts A or B. AIM is also available to those who have health insurance if their deductible or co-payment for maternity services is more than $500. For more information, visit the AIM website or call 1-800-433-2611.

MediCare, MediCare Part D, and MediCare Supplement

Visit our Medicare Supplement Insurance page for details on these programs.

Covered California: California's Healthcare Marketplace

As part of the Affordable Care Act, California created a health insurance marketplace called Covered California. Through Covered California, individuals, families, and small businesses can purchase insurance products sold by private insurers. Covered California also helps individuals and families determine if they qualify for the Medi-Cal program and subsidies from the federal government toward purchase of a private insurance plan. Visit Covered California for more information about getting coverage.

 

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