Individuals & Families

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.

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.

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.

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.

Where does my coverage need to come from? When can I buy coverage?

Coverage can be provided by an employer or purchased on the open market. There is a narrow window each year to sign up for coverage, and it is not generally possible to get coverage outside that time frame unless there is a qualifying event. The next open enrollment period for coverage starting in January of 2016 runs from November 1st 2015 to January 31st 2016.

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.