Individual & Family Health Insurance

If you cannot get health insurance from your employer or through government medical programs, you can purchase Health Insurance for yourself and/or your family.Health Insurance is available either directly with the health insurance carriers or through Covered California.

What is Individual Health Insurance?

It is a purchase directly by you for your family and not through your employer or the government

Because of the Affordable Care Act (ACA), plans cannot be denied due to pre-existing or chronic health issues.

Generally benefits and cost-sharing fall under the metal tiers: Bronze, Silver, Gold, and Platinum Cover 10 minimum essential benefits.

Plans fall under different types of coverage
Health Maintenance Organizations (HMO). This is the type of insurance where you are assigned and must see your doctor who is a Primary Care Provider (PCP). If you need a Specialist or need any diagnostic/therapeutic work, your PCP will refer you to what you need within the Medical Group or Independent Practice Associations (IPA) he or she belongs to.

Preferred Provider Organization (PPO). This is the type of insurance where you can self-refer to any PCP or Specialist to get diagnosed and treated. To get the most coverage, you must see doctors and go to facilities who are in-network. There is out-of-network coverage, but this will involve you paying a greater share of the medical expenses.

High Deductible Health Plans (HDHP). These are plans with no first dollar coverage. You have to set money aside to pay for these medical and pharmacy costs. You can set up a Health Savings Account (HS) to use the unique tax-advantages to cover a large portion of your deductible.

Minimum Coverage Catastrophic Plans. The ACA limits this category of insurance to those under 30 years old. This type of plan has a high deductible and will typically cover 3 PCP or urgent care visits per year with your responsibility being a low or no copay. Because of this coverage, Minimum Coverage Catastrophic Plans do not qualify for an HSA account.

Open Enrollment and Special Enrollment Periods

During open enrollment, anyone can sign up for or make changes to their health insurance plan without a qualifying event. In California, it typically begins on November 1 and lasts 90 days. The start date of this period can change year to year. The first available effective date is Jan 1 of the following year when enrollment or changes are complete on or before Dec 15. Effective dates for coverage are typically the first of the following month.

The Special Enrollment period is the period outside of Open Enrollment. You must have a Qualifying Life Event (QLE) to be able to get health insurance during this period. Qualifying Life Events for Special Enrollment include

  • Losing group health insurance or Medi-Cal
  • Moving into a new service area
  • Having a baby
  • Getting married
  • Gaining lawful presence
  • The time period to sign up for health insurance is on the day the QLE occurs up to the 60th day.

Why Obtain Health Insurance

When you purchase health insurance, it gives you peace of mind to know that if you are seriously ill or injured, you can see a doctor to help you heal. It also gives you the security of knowing that if you have a catastrophic illness or injury you will not be financially burdened or even need to file bankruptcy due to the cost of getting better.

As of 2020 California is imposing a State penalty for not having health insurance. In order to avoid the penalty, you must obtain health insurance.

When you get an Individual or Family Health

Insurance Plan, you should be on the lookout for A Primary Care Provider (doctor) will be assigned to you. This is the doctor you will see first to coordinate your care. If you have an HMO you must see this doctor before you see a specialist. If you have a PPO you can self-refer to another doctor other than your assigned PCP. In general, you must see doctors who are in-network in order for the insurance to pay some or all of the listed benefits.

Your insurance will not cover all your medical treatment. You should be aware of the cost-sharing with your insurance plan. This is broken down into the following:

Negotiated Fee Rate(NFR):  this is your cost for any medical treatment or procedure negotiated by the health insurance plan on your behalf. Typically this is a discounted rate compared to the Usual and Customary Rate (UCR) the doctor, hospital, or diagnostic/therapeutic facility will charge you.

Copay. This is the small fixed dollar amount you are responsible for per medical visit. It is normally asked for before service is rendered.

Deductible: this is the first dollar you pay out of pocket before your plan actually kicks in. The deductible is typically a large fixed dollar amount. An example is $2000. This an amount you may not pay upfront unless the medical visit will be more than the deductible. It occurs annually so when you pay the set amount you are done paying the deductible until the next calendar year.

Coinsurance: after you pay your deductible, the insurance plan will not pay 100% of the cost for treatment. Rather, they pay a large percentage of the cost with you still paying a percentage of the remainder.

Out-of-pocket limits/maximum: once your combined deductible and coinsurance reaches a certain amount, your plan will then pay 100% of the medical bill remainder, as well as, any other subsequent medical bills for the rest of the year.

Finding the right Individual or Family Plan that meets your needs and your budget can be complicated. As health insurance broker/consultants we can help simplify the process. Don’t hesitate to contact Halili Hilltop Insurance Agency for information and quotes for Individual and Family Plans for companies in your area. We can also help if you have an existing health plan and have questions or intercede on your behalf with the health insurance companies.

Office

2725 E Pacific Coast Hwy.
Suite #101
Signal Hill, CA 90755