A Personalized Approach to Your Insurance Needs
 
Frequently Asked Questions
Can I obtain health coverage outside of open enrollment?

 

Yes. There are two ways in which you can obtain coverage outside of open enrollment:

  1. Through a special enrollment period – if you lose your health coverage, get married, had a child, turned 26 years old, or moved out of your insurance coverage are you can qualify to enroll.  You must enroll within 60 days of your qualifying life event.

  2. Through your state’s Medi-Cal/Medic-Aid program or through the Children’s Health insurance Program (CHIP) if you qualify.

What is the difference between a deductible, a co-payment and co-insurance?

 

Deductible is the amount you must pay before the insurance plan begins to pay.  However, a medical deductible only applies to major medical events like hospitalizations, surgeries, and medical transportation.  A co-payment is a pre-determined amount which is paid for specific services.  For example: $25 for a doctor visit, $55 for a specialist, $35 for lab work, etc. Co-Insurance is the amount that a subscriber is responsible for paying after the insurance pays its part.  It is usually a percentage of the cost of services.  For example: in an 80/20 plan, the insurance carrier pays 80% and the subscriber pays 20%.

 

Do I have to pay my deductible before I receive any kind of medical care?

 

No.  Deductibles don’t apply to all services.  Most plans will cover routine doctor visits, including specialists, preventive care, prescription drugs, and other services. 

 

My deductible is $6,500 and so far I’ve only met about $500.  I was hospitalized for 10 days and the total cost of services received was $78,000.  Do I have to pay the other $6,000 all at once or can I make payments?

 

The hospital will bill you for the entire $6,000. However, you can contact the hospital billing dept. and make payment arrangements.  This, of course, is to the discretion of the hospital.

 

What does it mean when someone says, “subject to a deductible”?

It means that you must pay the cost of that service out of pocket if you have not yet met your deductible.  When a service is not subject to a deductible, it means that you do not have to pay the cost of that service.  You may still have to pay a co-payment, however, unless it is a preventive service.

What is an HSA?

An HSA (Health Savings Account) is a savings/investment account funded with your pre-tax dollars which can be used to pay for qualifying medical expenses. Funds in an HAS accont cannot be used to pay for health insurance premiums.  They can only be used for qualifying medical expenses.  If those funds are used for anything else other than qualifying medical expenses, there will be tax consequences.

I live in California but travel to other states quite often.  Can I use my California plan in other states?

Currently that is not allowed as each state regulates its own insurance market.  What this means is that insurance carriers negotiate fees and terms on medical services with hospitals and doctors within their state.  However, certain carriers are coming up with special programs that allow subscribers to use their insurance out of state.  That is not an industry standard though.

Can I be denied for pre-existing conditions?

As of this writing, the answer is NO.  Prior to 2014, it was possible to be declined for pre-existing conditions.  However, after the ACA provisions became law, it became unlawful for an insurer to decline an application solely based on pre-existing conditions.

Do I have to keep my insurance policy all year or can I cancel it at any time?

That depends on whether you have an employer sponsored policy or an individual/family policy.  If you obtained your insurance through your employer, then you are locked in for the entire year, unless you quit or get fired.  If your policy is an individual or family plan then you can cancel it at any time by contacting your health insurance provider.  Keep in mind that once you cancel your policy, you will not be able to re-enroll until the next open enrollment or if you have a qualifying life event.

When can I enroll?

 

Open enrollment begins on Nov. 1st each year and runs until the end  of January of the following year.  However, if you qualify for Medi-Cal, you may enroll at any time.  Medi-cal enrollment is year round.

I applied for Medi-Cal benefits but not received any information on the status of my case. What should I do?

Medi-Cal is most likely still processing your application.  Each county receives a vast amount of new applications daily and this large number of applicants processing takes longer than usual.  The usual time to process a Medi-Cal application is 30 days.  If it's been longer than 30 days and you would like to know that status of your application you may contact your county human services agency.  You can locate their information by visiting their website at: 

www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx.

What does my health insurance plan cover?

Most health insurance plans cover a variety of medical services, from regular check-ups to major medical procedures.  Each plan has what is known as a "Summary of Benefits".  The summary of benefits details all the benefits of the plan including deductible, co-payments, max-out-of-pocket, and medical services covered.

One important thing to keep in mind is that if your plan is an HMO, you need to see in-network-providers if you want your health plan to cover qualified expenses.  While some plans offer out-of-network benefits, most do not.

Are my premiums and medical expenses tax deductible?

Insurance agents are not qualified to give tax advice.  However, the general rule is that medical expenses, including premiums, are tax deductible on Schedule A.  However, not all medical expenses are tax deductible, only those expenses over 10% of you adjusted gross income if you are under 55, and 7.5% of your adjusted gross income if you are 55 or older.  

Please consult your CPA or tax professional for advice on this topic.

 
 
 
 
 
 
 
 
 
 
 
 

Co-pay

A set amount which you are required to pay when  seeking certain medical services

Deductible

The amount you must pay before the insurance begins to pay. The deductible does not apply to all medical services.

Premium

The amount that you pay monthly for your health insurance plan.

Co-Insurance

The amount that you have to pay after the insurance plan pays its share. It is a percentage of the cost of services provided.

 

Health Savings

Account

savings and investment account funded with pre-tax dollarswhich can be used to pay for qualifying medical expenses.

Max Out of Pocket

The maximum amount that you would be required to pay in a benefit year.