California Health Care Options, From Individual, Family Insurance Plans to State Programs

Health care in California is among the issues that have been raised as the state's recall election gets under way on September 14.

The Los Angeles Times reported Friday that California Gov. Gavin Newsom argues Republicans are looking to "take away health care access for those who need it," according to his statement in the voter guide sent to residents ahead of the election.

Health care in the state can be accessed through various types of coverage, from public programs for those on low incomes to individual/family health insurance plans and ones provided through an employer. Each operates under their own rules and are regulated by different government agencies.

Here we outline the current different basic health care options available to California residents.

Individual and Family Health Insurance

Residents can buy health insurance as an individual if they are not covered via their employer and do not qualify for one of the state's public health programs.

Once a person purchases their chosen health insurance, family members (as well as other dependents in some cases) can be added to be covered under their health insurance policy.

The California Department of Insurance (CDI), which regulates insurance in the state, including health insurance, explains that following the Affordable Care Act (ACA), consumers now have more protections when purchasing health insurance.

As outlined at the CDI website:

  • Insurers can no longer deny you coverage if you have a "pre-existing condition."
  • Insurers can no longer charge you more based on your health status.
  • The federal government offers subsidies to lower the cost of your premium if you meet certain income criteria.

Residents can contact companies directly to buy individual or family health insurance. See the CDI website for a list of health insurance companies licensed by the CDI.

Through the Affordable Care Act, California also created a health insurance marketplace known as Covered California, through which individuals, families and small businesses can buy health insurance from private insurers.

Covered California also helps residents determine whether they are eligible for any public health insurance programs, such as Medi-Cali (more on Medi-Cal below).

The logo for California Covered.
A logo for Covered California, a subsidized health insurance exchange and Medicaid administrator for California, seen on a paper in August 2019. Smith Collection/Gado/Getty Images

Employer Health Insurance and Self-Insured Plans

Employers and other associations purchase group health insurance policies, which are issued to individual employees or group members. Depending on the company, you may be able to add family members or dependents on your health insurance policy and your employer may require you to pay for a portion or all of the monthly premium, according to the CDI.

Many large companies are self-insured. The CDI says it is important to know whether your employer is self-insured or not, because you may not have the same protections and benefits as other types of health insurance coverage. Self-insured plans are not required to follow California laws on essential health benefits, complaints and coverage.

The CDI website says: "Self-insured plans issued by private (non-public) companies follow the Federal Employee Retirement Income Security Act of 1974 (ERISA) and are regulated by the U.S. Department of Labor, Employee Benefits Security Administration (EBSA)." See the EBSA website for more information.

Medi-Cal

Medi-Cal is the state's Medicaid health care program, which provides free or low-cost health coverage to millions of Americans, including those on a low income.

Funded by federal and state taxes, Medi-Cal, which consists of many different programs, offers several medical services for children and adults with limited income and resources, the government's Benefits.gov website explains.

To be eligible for California Medicaid, applicants must be a California resident, a U.S. national, citizen, permanent resident or legal alien, in need of health care insurance assistance, and "whose financial situation would be characterized as low income or very low income," Benefits.gov explains. They must also fall under one of the following categories:

  • Be pregnant
  • Be responsible for a child 21 years of age or younger
  • Be blind
  • Have a disability or a family member in your household with a disability
  • Be 65 years of age or older

In late July, Newsom signed a bill that expanded the Medi-Cal program to include undocumented Californians aged 50 and older and extended Medi-Cal eligibility for postpartum individuals.

Some uninsured middle-income pregnant women may also be eligible for the Medi-Cal Access Program (MCAP).

Medicare

Some California residents can also access Medicare, a federally-funded health insurance program for people aged 65 and older, people under 65 with certain disabilities, and people of any age with End-Stage Renal Disease (ESRD), which is a condition of permanent kidney failure requiring dialysis or a kidney transplant.

The California government website advises that Medicare does not cover all health care costs and residents may want to purchase other types of Medicare-related insurance such as Medicare Advantage or a Medicare Supplement policy.

See the CDI website for more information on Medicare Supplement Insurance (also known as Medigap).

HMOs and Managed Care Plans

Health Maintenance Organizations (HMOs) and managed care plans are different from traditional health insurance policies and operate under a different set of laws in California. As with health insurance policies, the health care coverage can be purchased either as "individual/family" or "group" plans, the CDI explains.

For HMOs, you are limited to using health care providers within the HMO network. Those under an HMO plan usually have a primary care doctor, who provides basic care and can refer you to specialists.

Services accessed from a health care provider outside of your HMO's network will not be covered by your HMO except in the case of emergency and urgent care. Other restrictions can apply for HMO plans.

HMOs and Managed Care Plans are regulated by the California Department of Managed Health Care (DMHC).

See the CDI website and the DMHC website for more information, including a list of managed health care plans in California.

Protesters in San Francisco.
Protesters demonstrating against proposed cuts to California's Med-Cal and Medicare programs, seen outside San Francisco city hall in September 2011. Justin Sullivan/Getty Images