This product generally provides coverage for hospital, medical or surgical services as described within the insurance policy provisions. California health insurance Applications for coverage are underwritten by Insurance Companies. Coverage is provided under a group or individual policy of insurance. Coverage and premium may vary from one policy to another.
- An employer or association (such as AARP) may choose to provide health benefits to their employees or members through a “group” insurance policy. The policy is issued in the name of the group. Certificates of Coverage are issued to the group members. Coverage may be extended to dependents/domestic partners.
- The policy is issued to the individual who applies for coverage. Coverage may be extended to dependents/domestic partners.
Insurance is subject to the laws in the State in which the policy is issued. In California, insurance products are regulated by the California Department of Insurance (CDI) www.insurance.ca.gov. Phone: 1-800-927-4357.
Coverage is provided as a Health Care Service Plan which is underwritten by an HMO or Managed Care Plan and is subject to the laws outlined in the California Health and Safety Code and is NOT governed by insurance laws.
Examples of HMOs include, but are not limited to:
- Blue Cross of California
- CIGNA Behavioral Health of California - Formerly: MCC Managed Behavioral Care of California
- CIGNA Healthcare of California, Inc. - Formerly: Ross Loos Health Plan of California
- Delta Dental Plan of California - Formerly: California Dental Services
- Health Net – HMO – AKA Foundation Health Plan A California Health Plan
- Kaiser Foundation Health Plan, Inc. – Permanente Medical Care Program
- Maxicare
- Pacificare of California – Secure Horizons: Health Plan of America
- Prudential Health Care of California – Prucare Plus
Scan Health Plan
Coverage is issued as either a Group or Individual Health Care Service Plan.
Managed Care Plans are regulated by the California Department of Managed Health Care (DMHC) www.dmhc.ca.gov. Phone: 1-888-466-2219.
For a complete list of Managed Care Plans, please visit the DMHC web site.
NOTE: Medicare Advantage/HMO plans are not directly regulated by the Department of Managed Health Care. These plans are regulated by the federal government through the Centers for Medicare and Medicaid Services (CMS). http://www.cms.hhs.gov. Phone: 1- 877-267-2323
These plans are not underwritten by either an Insurance Company or a Health Care Service Plan. Coverage is provided for a group and is financed by the self insured entity. Example: A large employer or union may find it economically advantageous to pay the cost for medical services for its employees subject to the terms and conditions of the plan rather than purchase either a group insurance policy or a group Health Care Plan.
Self-Insured plans issued by private (non-public) companies are subject to the Federal Employee Retirement Income Security Act of 1974 (ERISA). This law is enforced by the U.S. Department of Labor, Employee Benefits Security Administration.
The Department of Labor may be reached at 1-866-275-7922 or 1-866-444-3272 or www.dol.gov/ebsa.
Note: ERISA law does not apply to self insured group health plans established and run by governmental entities or churches.
Examples of non-federal publicly funded plans include: State, County, and Municipal agencies, School Districts, County Hospitals, Cal-Pers self funded health programs. Information regarding the laws that govern these plans may be obtained from the Centers for Medicare and Medicaid Services at http://www.cms.hhs.gov/SelfFundedNonFedGovPlans. Phone: 1-877-267-2323
Federal Governmental Self-Funded Plans are not directly regulated by the Federal government. For information on the laws that govern these plans you must contact the specific agency directly.
Medi-Cal is California’s version of the federal Medicaid program. This program pays for health services for California residents that qualify based on income and assets. Eligibility is determined by the Department of Health Services(DHS) through its sub-agency Department of Public Social Services (DPSS). Eligibility, enrollment, and complaints are handled by local DPSS offices which are located in each county. This program is regulated through the California Department of Health Services http://www.dhs.ca.gov/mcs/medi-calhome/default.htm. Phone: 1-916-552-9400
A list of phone numbers for the various DPSS offices by county is available at http://www.dhs.ca.gov/mcs/medi-calhome/CountyListing1.htm.
This agency administers the following three programs which are under the jurisdiction of the California Heath and Human Services agency (CHHS) http://www.chhs.ca.gov.
Program information may be located at the CHHS web site.
The program is designed primarily for uninsured low income pregnant women and their infants who do not qualify for Medi-Cal. AIM is also available to those who have health insurance if their deductible or co-payment for maternity services is more than $500. Once qualified for AIM, the newborn is automatically eligible for enrollment in the Healthy Families Program. Phone: 1-800-433-2611
This program provides low-cost comprehensive health, dental and vision coverage for children and teens up to age 19 who do not have access to insurance and do not qualify for Medi-Cal. If the mother qualifies for AIM, the baby is automatically eligible for enrollment in Healthy Families. Phone: 1 888-747-1222
This program provides comprehensive health insurance for Californians who are unable to obtain coverage in the individual health insurance market. People enroll in the program because they have been rejected for coverage by an insurance company or health plan due to a pre-existing condition. Phone: 1-800-289-6574.
