Individuals & Families

Why isn't my doctor in network?

Not all doctors contract with all plans, it's best to check out provider directories and to double check with your doctor before scheduling any visits.

How does getting a subsidy work? Do I qualify?

To get a quick idea if you qualify for a subsidy, please visit the Covered California Shop and Compare Tool. If you are not eligible for a subsidy, you can actually apply online for many plans available through our quote page, or contact us to walk you through it. If you are eligible for a subsidy and have a qualifying life event, we would be happy to assist you in signing up for a Covered CA plan.

Why do I need to buy insurance, anyway?

There is a requirement under the Affordable Care Act, frequently referred to as Obamacare, that all legal residents of the USA have coverage compliant with the new plan requirements. There are tax penalties for deciding not to purchase insurance. For members with coverage starting in 2015, this is 2.0% of your overall income, or $295, whichever is larger. For coverage beginning in 2016, the penalty will be 2.5% of your overall income or $695, whichever is larger.

What happens if I don't have control over who treats me in an emergency situation? For example, an ambulance, anesthesiologist or an assisting surgeon in an emergency room?

These claims will often be declined or considered as out of network. Please use our services to help you attempt to get reimbursement on an in-network basis. We have a good track record with helping sort out claims problems, although we cannot guarantee this will always work out.

What happens if use providers who are not in my network?

In some plans, these providers are not covered at all. In other plans, they are covered to a much lower level. It is highly recommended not to go out of network if at all possible. If you must see an out of network provider for an emergency issue, this would be paid as an in-network expense.

What is an Out of Pocket Maximum (OOP)?

This is the maximum amount you could be required to pay out for claims incurred during any calendar year, provided that you are only using in-network services. The maximum is considerably higher if you use non-network services, so try to stay in the network.

What is a copay?

The amount you typically pay for office visits, laboratory tests, X-rays and prescriptions. After you pay the copay for these services, the insurance company typically pays the remainder. There are different copays and limits for out of network care, so try to stay in network whenever possible.

Is there a deductible for the plans you offer, and what is a deductible, anyway?

It varies depending on the plan. Similar to your insurance, a deductible is the amount you pay in full up front before the insurance company steps in and pays the lion's share of the costs. However, there are some services that you pay for on a strict copayment structure that you do not need to meet the deductible for. These include almost all basic medical visits.

Does it matter if I have a pre-existing health condition?

No. Under the Affordable Care Act, there are no health questions asked and no effect on rates if you have a condition.

What would allow me to buy insurance outside of the open enrollment period?

There are a wide variety of Qualifying Life Events that could permit you to buy coverage on the open market or through Covered California. Generally speaking you may qualify for any involuntary loss of coverage, significant income change, getting too old to stay on a parent's plan, changing residency or marital status, having a child, acquiring citizenship, and many others. Covered California provides a useful reference for the types of qualifying events.