Paul Sanchez
California offers its residents a variety of health insurance options, including group insurance through employers, individual policies, and government-assisted insurance. The state has created a health insurance marketplace called Covered California, where individuals, families, and small businesses can purchase insurance products from private insurers and explore financial assistance options. California's insurance landscape also includes self-insured plans, Medi-Cal (California's version of Medicaid), and various types of health insurance plans such as EPO, HMO, and PPO. Understanding these choices is essential for making informed decisions about healthcare coverage.
| Characteristics | Values |
|---|---|
| Name of California's Health Insurance Marketplace | Covered California |
| Website | www.coveredca.com |
| Phone | (800) 300-1506 |
| Types of Insurance Plans | Exclusive Provider Organization (EPO), Preferred Provider Organization (PPO), Health Maintenance Organization (HMO) |
| Types of Coverage | Individual, Family, Small Business |
| Benefits | Vision care, dental care, health and mental health care, doctor visits, hospital care |
| Financial Help | Yes, based on income |
| Yearly Enrollment | Yes, open enrollment period |
| Special Enrollment | Yes, for major life changes |
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What You'll Learn
California's health insurance marketplace
California offers its residents a variety of health insurance options. The state-run health insurance marketplace in California is called Covered California. It is California's official health insurance marketplace, where 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 federal subsidies to purchase a private insurance plan.
Medi-Cal is California's version of the federal Medicaid program. It is California's public health insurance program for families and individuals, including people with disabilities, and covers an array of medical procedures, office visits, and other health-related expenses. It is available to those who qualify and is free of cost. Enrollment is open all year round.
California residents can also purchase individual health insurance policies from a licensed health insurance agent or from an insurance company. There are many kinds of individual policies, with different costs and benefits, and residents are advised to study their choices carefully so that they can choose the one that best suits their needs.
Most people in California get group health insurance through their employer, also known as employee coverage. Employers with 100 or more employees buy large-group policies, while those with fewer than 100 employees buy small-group policies. In most cases, group insurance is better than individual insurance as it gives more benefits at a lower cost. Self-insured employers have a large pool of money and use it to pay for the health care of employees, often contracting with insurance companies to manage the health benefits.
California has a range of health insurance options, and understanding the differences between them is crucial for making an informed decision.
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Medi-Cal
In California, most people get group health insurance through their job, also known as employee coverage. However, Medi-Cal is California's Medicaid healthcare program, which provides free or low-cost health care for children and adults with limited incomes and resources. Eligibility for Medi-Cal is based on several factors, including income level, with a maximum threshold of 138% of the Federal Poverty Level (FPL) for adults and 266% FPL for children.
Covered California offers a range of health, dental, and vision care plans, with lower monthly premiums available for those who qualify for financial aid. This financial assistance is provided through the Affordable Care Act (ACA), which helps ensure that Americans have access to affordable health insurance. On-exchange health plans are available through Covered California, while off-exchange plans can be purchased directly through providers like Anthem Blue Cross.
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Group insurance
In California, most people get group health insurance through their employer, also known as employee coverage or employer-based coverage. Employers with 50 or more employees purchase large-group policies, while those with fewer than 50 employees buy small-group policies. Small group employers can purchase plans through CalChoice, Covered California for Small Business (CCSB or SHOP), or directly from an insurance company.
There are several insurance companies that offer group health insurance coverage in California. Anthem Blue Cross, the California subsidiary of Anthem, Inc., offers HMO, PPO, and HSA plans to small businesses with deductibles ranging from $0/year to $6,000/year. One of the benefits of Anthem Blue Cross is the large number of doctors and hospitals in their PPO and HMO networks. They also offer a smaller, more affordable "Select" network of doctors and hospitals.
Kaiser is another popular option for California group health plans. Kaiser contains costs better than other California group health plans because doctors are paid salaries for their services, as opposed to traditional arrangements where doctors and hospitals are paid for each test and procedure they perform. Kaiser offers high-quality comprehensive benefits at a low cost relative to other companies, as well as co-payment HMO plans, deductible HMOs, and HSA-compatible plans. They also offer PPO plans, but these are typically not competitive in terms of pricing.
Blue Shield of California is a non-profit health insurance company that covers Californians and out-of-state employees of employer-sponsored plans through the Blue Cross Blue Shield Blue Card system. Blue Shield offers full "Access Plus" HMO plans, which enable members to go directly to certain specialists within designated medical groups, and "Local Access" HMO plans, which have fewer doctors and hospitals and are less expensive. They also offer competitive group dental, vision, and life insurance plans.
It is important to note that self-insured plans are not required to cover all the same services as traditional insurance policies or health plans, so it is beneficial to understand if your employer self-insures as your benefits and protections may differ. Additionally, while group insurance typically offers more benefits at a lower cost than individual insurance, it is still important to carefully review your policy to understand your costs, benefits, and the services that are not covered.
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Self-insured plans
The state's large employers, particularly those with 5,000 or more employees, tend to opt for self-funded plans. This is because they offer cost savings and greater control over employee health benefits. Self-funded plans allow employers to pay for claims directly out of pocket, avoiding the high premiums associated with fully-insured plans. They can also tailor the plan to meet the specific needs of their workforce, offering customized coverage options. However, this control comes with financial risk, as employers must have strong cash flow and financial reserves to handle the unpredictability of healthcare costs.
To protect against catastrophic or high-cost claims, employers often purchase stop-loss insurance. This coverage kicks in when claims exceed a certain threshold, limiting the employer's financial exposure. In California, the Office of Self-Insurance Plans (OSIP) is responsible for the oversight and regulation of workers' compensation self-insurance. OSIP also ensures that self-insurers post the required security deposits to collateralize against potential defaults. As of January 1, 2025, there were 7,107 California employers that were active self-insurers.
California's self-funded insurance plans align with the state's broader move towards more flexible and customizable health coverage options. This trend has resulted in a growing number of California's workforce being covered by self-funded plans.
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EPO, HMO, and PPO plans
In California, individuals can purchase health insurance from an insurance company, a licensed health insurance agent, or from Covered California, California's Healthcare Marketplace. There are various types of health insurance plans available, including EPO, HMO, and PPO plans.
EPO (Exclusive Provider Organization) plans offer a local network of doctors and hospitals, with a larger network than HMOs. EPO plans only cover in-network care, and may or may not require referrals. EPOs have higher premiums than HMOs but lower premiums than PPOs. EPOs are a good choice if you want lower monthly premiums and are comfortable with a limited network of providers.
HMO (Health Maintenance Organization) plans are one of the least expensive options, with lower monthly costs, deductibles, and copays. HMOs have a limited network of doctors and hospitals, and you need to choose a primary care physician (PCP) who will refer you to specialists. HMO plans often require you to live or work in their service area to be eligible for coverage.
PPO (Preferred Provider Organization) plans offer a large network of doctors and hospitals, giving you more choices. PPOs have higher monthly costs and higher out-of-pocket expenses, but you can see specialists and out-of-network doctors without referrals. PPO plans are good if you want the flexibility to see any doctor and don't mind paying higher premiums.
California residents can also consider other types of health insurance plans, such as POS (Point of Service) and HDHP (High-Deductible Health Plan) plans, as well as financial assistance options like the Affordable Care Act (ACA) subsidies.
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Frequently asked questions
Covered California.
Covered California is a health insurance marketplace created as part of the Affordable Care Act (ACA). It allows individuals, families, and small businesses to purchase insurance products sold by private insurers.
Covered California offers health, dental, and vision care insurance. It also provides Medi-Cal, California's version of the federal Medicaid program, which covers medical procedures, office visits, and health-related expenses for lower-income Californians.
You can contact Covered California or your county's social services offices to determine if you qualify for Medi-Cal.
California offers a variety of health insurance options, including Exclusive Provider Organization (EPO) plans, Preferred Provider Organization (PPO) plans, and Health Maintenance Organization (HMO) plans. These plans differ in terms of provider networks, referral requirements, and cost structures.
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