Using Your Covered California Health Insurance

Celebration!

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Congratulations! You have health insurance!

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Health Insurance Process

Now what do you do?

What is Health Insurance?

Health insurance is a way to pay for health care. It protects you from paying the full costs of medical services when you’re injured or sick.

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Just like car insurance you choose a plan and agree to pay a certain rate each month. This is called a premium.

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Health Insurance Process

You should have received a health insurance cardHealth insurance company

Should have

Covered California

logo

Doctor name and phone

number**Make sure you have the correct

Doctor.

Children are in a dental

program

Member ID

Health Insurance Process

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The amount you owe for health care

services before you health insurance company pays.

Example: You pay $2,000 for individual or $4,000 for family

and health insurance pays.

Deductible

Health Insurance Process

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The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100 percent of the

allowed amount.

Example: After you pay $6,350 for an

individual or $12,700 for a family and health insurance pays 100%.

Out-of-Pocket (OOP) Cost

Health Insurance Process

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Co-Insurance

Your share of the costs of a covered health care service, calculated as a percentage (for example, 20 percent) of the allowed amount for the

service. You pay coinsurance plus any deductible you owe.

Example:  If the health insurance plan's allowed amount for an office

visit is $100, and you have met your deductible for the year, your

coinsurance payment of 20 percent would be $20. The health plan pays

the rest of the allowed amount.

Health Insurance Process

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A fixed amount you pay for a covered health care service,

usually when you receive the service.

Example:  When you have a doctor appointment, you pay $45.

Co-Payment

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Health Insurance Process

When do I contact Covered California and/or the Health Insurance Company?

Covered California• Changes in application

information• Income• Name• Address• Phone Number• Dependents

Health Insurance Company• Primary Care Provider• Payments• Claims• What your benefits cover

What is included in my health plan?

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Health plans = a package of health benefits and services.

Cost will depend on your

insurance plan

What are Preventive Services?

•Services or measures taken to prevent diseases instead of curing or treating them and to maintain proper health

•What is covered:–Yearly physical checkups–Well-woman visits

•Mammograms•Pap smears

– Immunization shots•Flu shots•Hep A & B

•Preventive services are FREE! Your doctor should NOT charge you for these services!

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Why are Preventive Services important?

•Preventing an illness is much easier and less expensive than managing or curing one after it has begun

•Reduce or eliminate risks for chronic conditions•Early prevention and diagnosis is key!

–Even if you do not feel sick, symptoms may be lurking inside your body

–Need to do early preventive screenings and tests to detect the early warning signs

•Remember: Preventive services are FREE! Your doctor should NOT charge you for these services!

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How to get health services?

Make sure you have the correct doctor you want on your insurance card.

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The doctor listed on your card is called your primary care provider.

Call your doctor’s office to schedule an office.

What services can my doctor provide?

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A specialist, is a expert in a medical practice such as the

heart, lung, brain, skin, etc.

PPO• Don’t have to see in-

network doctor for insurance company to pay

• Insurance company will pay more of the costs of in-network doctors

• Can go to a Primary Care Provider or a specialist on your own

HMO• Must see in-network

doctor for insurance company to pay

• Must have a Primary Care Provider that will provide general health services, such annual exams & assess your health problems

• Only your PCP can refer you to see a specialist

Depends on your plan

EPO• Must see in-network

doctor for insurance company to pay

• Can go to a Primary Care Provider or a specialist on your own

How the ACA Helps You Appeal Health Plan Decisions

•New standardized legal protections –If you and your health plan disagree about your care or coverage, you have new rights to help you challenge their decision

–These protections apply only to health plans set up after March 23, 2010

–Medi-Cal and Medicare already follow these appeal rules

•You have a right to appeal if your plan: –Refuses to give you health care–Refuses to pay for your health care–Cancels your insurance

•Your plan must give you a notice explaining: –Why they made the decision –How you can appeal the decision –How long you have to file your

appeal

Your Appeal Rights

Language Access

•In CA, if you do not speak English and need help to explain your side to the health plan:

–You have the right to an interpreter –You may receive written information about appeal

rights in your language •Depending on the language

–Call your health plan to request these language services

Appeal Process: Level 1 Appeal

Someone who works for your health plan will review the plan’s decision to see if it is correct

•Your health plan must let you: –Review your file –See the information the plan used to make its decision–Give new or missing information you think is important

and may help the reviewer change the plan’s decision

You have a legal right to review your file.

Your plan cannot charge you for this.

Level 1 Appeal

•If you win, you will get the coverage or service you asked for

•If you lose, your plan must explain in writing why they denied your appeal

•Your health plan must decide within: –72 hours for urgent care –30 days for non-urgent care you are waiting for –60 days for services already received but your health plan

refused to pay for

Appeal Process: Level 2 Appeal

• You may have the right to appeal to an independent reviewer, if you lose on Level 1 appeal

–If HMO, contact California Department of Managed Health Care

–If PPO, contact California Department of Insurance

For Medi-Cal, you can appeal beyond DMHC and request a court hearing with an administrative judge.

Resources

•Covered California –www.coveredca.com– 888-975-1142

•Medi-Cal and Medi-Cal Managed Care – www.dpssbenefits.lacounty.gov/ybn/Index.html– 888-442-2273

•Asian Americans Advancing Justice - Los Angeles–www.advancingjustice-la.org– 213-977-7500– 213-241-0284 (Connie Lo)

•Chinatown Service Center– 213-808-1700

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Health Plan Problems

•For HMOs: 888-466-2219 – California Department of Managed Health Care (DMHC)

•For PPOs: 800-927-4357 –California Department of Insurance (CDI)

•Legal Assistance–Private Health Plan Problems:

•Health Consumer Center of Los Angeles: 800-896-3203

–Medi-Cal Managed Care Health Plan Problems:•Legal Aid Foundation of Los Angeles: 323-801-7912

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