California Health Insurance - Federal Requirements
Most health insurance is regulated on the state level. The federal government has several laws that protect Americans and help to assure availability and affordability of health insurance coverage. These include:
The Affordable Care Act - The health reform legislation, signed into law in March 2010, makes significant changes to the U.S. healthcare system. Most of the changes deal with the availability of affordable health insurance.
COBRA - Provides some former employees, retirees, spouses, and dependents the right to buy temporary continuation of group health plan coverage at group rates. COBRA may be an option for health insurance if you have been laid off.
HIPAA - Provides protection for you and your family when you need to buy, change, or continue your health insurance. These protections include limits on the use of pre-existing condition exclusions and usually guarantees that you can renew your coverage regardless of any health conditions in your family.
A Dr. Mike Tip: If you have concerns about how your employer administers your job-based health coverage - for example, if you think you should have been offered COBRA continuation coverage, but were not - contact the regional office of the U.S. Department of Labor (DOL) Employee Benefits Security Administration. You can find the contact information on the DOL website.
The federal government also funds and sets guidelines for Medicare, Medicaid, Veterans Health Benefits, many federal employees (including members of Congress), and health coverage for members of the Armed Forces.
However, most health insurance plans are regulated by your state government. Since the states differ considerably in the rules they set for health plans – such as mandating certain benefits – and the types of state health insurance programs offered, it is important that you understand what is unique about your state.
Health Insurance in California
Several state agencies regulate health insurance in California, including:
- California Department of Health Care Services – pays for and manages the California Medical Assistance Program (Medi-Cal), California Children’s Services program, and the Child Health and Disability Prevention program.
- California Managed Risk Medical Insurance Board – directs three programs including the state’s high-risk insurance pool, the Access for Infants and Mothers program, and the Healthy Families Programs
- Department of Managed Health Care – California has strong patients' rights laws and this department is the only stand-alone HMO watchdog agency in the nation.
- California Department of Insurance – responsible for enforcing many of the insurance-related laws of the state and acts as a portal for health insurance information.
California Pre-Existing Condition Insurance Plan
The Pre-Existing Condition Insurance Plan (PCIP), which is administered by either your state or the U.S. Department of Health and Human Services, may provide health coverage for you if you have been uninsured for at least six months, you have a pre-existing condition or have been denied health coverage because of your health condition, and are a U.S. citizen or are residing here legally.
In California, the PCIP will be run by the state agency that currently manages California’s high-risk pool.
California Programs for People with Low Incomes or Special Needs
California has several programs each of which is designed to meet the healthcare needs of a certain group of people. Each program has different eligibility criteria depending on family income and health status. These programs include:
Traditional Medicaid (Medi-Cal)
Medi-Cal, California’s traditional public health insurance program (Medicaid), provides needed health care services for low-income individuals including families with children, seniors, persons with disabilities, children in foster care, pregnant women, and low income people with specific diseases such as tuberculosis, breast cancer or HIV/AIDS.
A unique program managed by Medi-Cal is the Breast and Cervical Cancer Treatment Program, which provides needed cancer therapy for eligible women who have been diagnosed with breast and/or cervical cancer and need treatment.
Healthy Families is a low-cost insurance plan for children and teens. It provides health, dental and vision coverage to children who do not have insurance and do not qualify for Medi-Cal. Members pay a premium each month of $4 to $24 for each child, or no more than $72 for a family. Members also pay a co-payment (usually $5 to $15) when they go to the doctor or get other services. Some services are free.
Access for Infants and Mothers (AIM)
The AIM Program provides low-cost health care coverage for pregnant women. Their newborns may be covered by the Healthy Families Program. AIM is for middle-income families who don’t have health insurance and whose income is too high for Medi-Cal. AIM is also available to California women who have health insurance if their deductible or co-payment for maternity services is more than $500. If you are enrolled in AIM, your baby is eligible for enrollment in Healthy Families unless your baby is enrolled in employer-sponsored insurance or Medi-Cal.
Child Health and Disability Prevention (CHDP)
CHDP is a prevention program that offers periodic health assessments and services to low income children and youth in California. CHDP provides services to assist families with medical appointment scheduling, transportation, and access to diagnostic and treatment services. Health assessments for children are provided by some private physicians, local health departments, community health centers, managed care plans, and some local school districts.