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California health insurance  -  Group health insurance in California  -  Important insurance terms 

California Health Insurance Terms

Most of the "Terms" webpages out there partially require that you're already well versed in California health insurance and they also have a lot of terms that you'll probably never need. We want to keep it straight forward and provide the big-ticket terms that will help you really understand your options on the market. Of course, we many articles which will allow you to dig as deep as you wish on any given topic. So let's begin with the top of the hierarchy in a plain and simple language.

Plan Types:

PPO. Preferred Provider Organization.

A type of health insurance plan that allows you more flexibility to access doctors/hospitals at a negotiated rate but requires more cost sharing. Currently dominates Individual Family market and increasing on Small Group side.

HMO. Health Maintenance Organization.

A type of health insurance plan which allows for richer benefits but is more restrictive in terms of accessing health care and providers. HMO's have been priced out of the Individual Family market but remain viable on the group side.

HSA. Health Savings Account.

Combines high deductible PPO (mostly) health plan with a tax-favored checking account. The theory is that you receive a tax benefit to encourage savings for smaller bills while using high deductible plan for more catastrophic needs.

Market Segment:

Individual and Family.

Refers to pre-65 private health insurance market in California for people without Medicare, Group health, or other options. Currently medically underwritten (subject to health) but will be guaranteed issue effective Jan 1st 2014.

Group Health Insurance

Refers to health insurance provided by employer. Subject to AB1672 which made group health guaranteed issue (regardless of health) down to 2 lives after meeting certain eligibility requirements.
Medicare Supplements.

Private health insurance plans which supplements traditional Medicare for individuals 65 and older or permanently disabled.
Catastrophic. Refers to lower cost health plans designed to cover very large health insurance bills.

Plan Benefits:

Copay.

Fixed dollar amount you pay for certain services (usually office visits and RX) as part of health insurance benefits usually before deductible is met.

Deductible.

Fixed amount you must pay first before the plan starts to help with medical expenses. Calendar year Jan-Dec.
Coinsurance. Shared percentage that you pay (usually after deductible) until you hit the max out of pocket.
Max out of Pocket. Annual cap on your exposure according to health plan benefits. Assumes in-network and eligible expenses.
Use of Plan:
EOB. Explanation of benefit comes from the carrier after each medical service with detail on how the plan has paid.
Negotiated Rate. Discounted PPO rate for using in-network providers. Usually 30-60% lower than initial charge.
Preventative Benefits. Now covered at 100% on newer plans for services such as annual routine physicals, annual pap/mammogram, and well-child check ups.
Maternity.

Coverage of pregnancy and delivery is now covered on all California health insurance plans effective July 1st, 2012.

Health Reform:

A series of Federal laws governing changes to the health insurance market. The first round of changes went into effect 3/23/2010 (guaranteed issue for children, preventative benefits, dependents stay on plan till age 26). The next big change will bring guaranteed issue to all Californian's effective Jan 1st, 2014 through Exchanges with subsidies based on income.

 

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