A Californian’s Guide to Individual Health Insurance Options [INFOGRAPHIC]

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If you are a working adult who does not receive insurance through your employer, a senior citizen, a college student seeking your own health coverage, or an individual with a disability, then this informational guide is for you!

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Factors that Affect Healthcare Pricing

Pricing is based on four factors:

  • Age – elderly pay up to three times more than young people
  • Residence – people who live in high cost health care areas (i.e. major cities like Los Angeles and New York) will have to pay a bit more for healthcare
  • Family size – the more people in your family, the higher your healthcare costs
  • Tobacco use – people who use tobacco may pay up to 1.5 times more than non-tobacco users (however, some states have ruled this factor out when considering pricing)

The Most Popular Health Insurance Options for Individuals Seeking Independent Coverage in California

  • HMO (Health Maintenance Organization)
    • Pricing: Relatively low monthly premiums, copays, and out-of-pocket costs (compared to PPOs)
    • Flexibility: Moderate flexibility (compared to PPOs)
      • You must choose a primary care physician
      • Your doctor has to refer you if you need to see a specialist
    • Out-of-network coverage: Not covered (some exceptions for emergency situations)
    • Claim filing: Not necessary
      • The provider is not allowed to send you a bill directly
      • The provider bills your insurance and your insurance bills you
    • Coverage is similar to PPOs:
      • Preventative care, doctor visits, hospital stays, emergency care, maternity care, children’s care, prescriptions, medical tests, and mental health care
    • PPO (Preferred Provider Organization)
      • Pricing: Relatively high premiums, copays, and out-of-pocket medical services costs (compared to HMOs)
      • Flexibility: Highly flexible
        • More choices when selecting providers
        • Do not have to designate primary care physician
        • Do not need a referral from her primary care physician to see a specialist
      • Out-of-network coverage: Covered for a slightly higher fee
      • Claim filing: Sometimes necessary (i.e. when you see an out-of-network physician)
      • Coverage is similar to HMOs:
        • Preventative care, doctor visits, hospital stays, emergency care, maternity care, children’s care, prescriptions, medical tests, and mental health care
      • Medi-Cal
        • Available to:
          • Low-income families (annual income less than 138% of federal poverty level)
            • 2 people in household – below $21,983
            • 3 people in household – below $27,724
            • 4 people in household – below $33,465
            • 5 people in household – below $39,206
          • Seniors (65+)
          • Adults with disabilities
          • Single adults (without children) who are in need
            • 1 person in household – below $16,243
          • Covers:
            • Preventative care, doctor visits, hospital stays, immunization, maternity care, nursing home care, mental health care, prescriptions, children’s care, medical tests, chronic disease management
          • Medicare
            • Available to:
              • Seniors (65+)
              • Adults with disabilities
              • People with end-stage renal disease
              • Note: You are automatically enrolled if you have been receiving Social Security payments (unless you opt out)
            • Original Medicare
              • Part A – applies to coverage of hospitalization expenses
              • Part B – applies to coverage of doctor visits, lab tests, and preventative screenings
              • Part D (add-on for extra charge) – offers prescription coverage
              • Out-of-pocket cap or maximum: No
            • Medicare Advantage (Part C) – run by private insurance companies but regulated by the government
              • Coverage: similar coverage compared to original Medicare, but with included prescription coverage
              • Out-of-pocket cap or maximum: Yes

Covered California: Approved Insurance Companies for 2015

  • Anthem Blue Cross of California
  • Blue Shield of California
  • Chinese Community Health Plan
  • Health Net
  • Kaiser Permanente
  • A. Care Health Plan
  • Molina Healthcare
  • Sharp Health Plan
  • Valley Health Plan
  • Western Health Advantage

Note: You may purchase health insurance through Covered California or directly from an insurance company or broker (the plan will be the same price no matter where you purchase it)

AdminA Californian’s Guide to Individual Health Insurance Options [INFOGRAPHIC]