Health Insurance
How Do I Get Health Insurance

Health insurance is generally available through groups and to individuals.

Premiums—the regular fees that you pay for health insurance coverage—are generally lower for group coverage. When you receive group insurance at work, the premium usually is paid through your employer.

Group insurance is typically offered through employers, although unions, professional associations, and other organizations also offer it.

As an employee benefit, group health insurance has many advantages. Much—although not all—of the cost may be borne by the employer. Premium costs are frequently lower because economies of scale in large groups make administration less expensive.

With group insurance, if you enroll when you first become eligible for coverage, you generally will not be asked for evidence that you are insurable.

(Enrollment usually occurs when you first take a job, and/or during a specified period each year, which is called open enrollment.) Some employers offer employees a choice of fee-for-service and managed care plans. In addition, some group plans offer dental insurance as well as medical.

It should be noted that some employers, and others who offer group insurance to their members (such as professional organizations) are seeking to contain the costs of offering health benefits. In response, insurers and health plans are designing new types of benefit plans, and now offer (for example) tiered copayment levels for hospital and/or prescription drug coverage.

Employers are also seeking to contain costs by offering policies or benefits that differentiate among employees or members of the group according to various criteria. These criteria may include health status, claims history, length of time since underwriting occurred, old hires versus new hires, or full-time versus part-time. Thus, it’s important for employees (or association members) to be aware of how premiums are calculated and to understand the details of the policy being offered, such as copays and deductibles.

Individual insurance is a good option if you work for a small company that does not offer health insurance or if you are self-employed. Buying individual insurance allows you to tailor a plan to fit your needs from the insurance company of your choice. It requires careful shopping, because coverage and costs vary from company to company. In evaluating policies, consider what medical services are covered, what benefits are paid, and how much you must pay in deductibles and coinsurance. You may keep premiums down by accepting a higher deductible.

How Is Health Insurance Marketed in California?

California Health Insurance coverage is sold to consumers through individual policies or group policies. Individual health insurance coverage should be pursued when your employer does not offer health insurance as a benefit of employment, when you cannot be named as the dependent on another person’s insurance policy, or when you are not a member of a professional or trade association that offers group coverage.

Many consumers are self-employed, contract employees, or work for small employers and do not have access to a group policy secured by an employer. Individual coverage can be obtained by contacting a licensed health insurance agent or broker. You will need to complete an application that includes your medical history, which will be reviewed by a medical underwriter at the health insurance company. If you meet the underwriting qualifications and are issued a policy, the company may not cover preexisting conditions up to one year after the effective date of the policy. However, if you have been previously insured under an individual or group policy without a break in coverage of more than 62 days, your new insurance company must apply the prior creditable coverage (refer to the “Health Insurance Terms” section below) towards any waiting period for preexisting conditions. Individual health insurance companies may reject your application based on your medical history.

California Group health insurance offers certain advantages over individual health insurance policies. The waiting period for preexisting conditions is six months for policies covering 3 or more persons, not one year as with individual policies. Also, if you have been previously insured under a group policy without a break in coverage of more than 180 days, your new insurance company must apply the prior creditable coverage toward the six-month waiting period for preexisting conditions. Large employer group health insurance (more than 50 employees) and association group health insurance, like individual health insurance, is subject to medical underwriting. You can be denied coverage based on your medical history. Medical underwriting rules for small group health insurance (2-50 employees) differs from large group and individual health insurance policies. Regardless of any preexisting condition, you must be offered coverage under a small group policy on a guaranteed issue basis. However, the small group insurance company can utilize the six-month waiting period for preexisting conditions. Of course, if you have prior creditable coverage it must be applied to decrease or eliminate the waiting period.

Important Points to Remember About Individual and Group Health Insurance Coverage:

  • Health insurance coverage is sold to consumers under either individual or group policies.
  • Individual and large group policies are subject to medical underwriting.
  • Qualifying creditable coverage must be applied towards the year waiting period for preexisting conditions in individual policies and towards the six-month waiting period for preexisting conditions in group policies.
  • Small group policies require that coverage be offered on a guaranteed issue basis regardless of any preexisting condition.

California Health Insurance and Quote | California State Health Insurance | CalHealth