Using Your Covered California Health Insurance
Celebration! Congratulations! You have health insurance! 2
Health Insurance Process Now what do you do? 3
What is Health Insurance? Health insurance is a way to pay for health care. It protects you from paying the full costs of medical services when you re injured or sick. Just like car insurance you choose a plan and agree to pay a certain rate each month. This is called a premium. 4
Health Insurance Process Health insurance company You should have received a health insurance card Should have Covered California logo Member ID Children are in a dental program Doctor name and phone number **Make sure you have the correct Doctor. 5
Health Insurance Process Deductible The amount you owe for health care services before you health insurance company pays. Example: You pay $2,000 for individual or $4,000 for family and health insurance pays. 6
Health Insurance Process Out-of-Pocket (OOP) Cost The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100 percent of the allowed amount. Example: After you pay $6,350 for an individual or $12,700 for a family and health insurance pays 100%. 7
Health Insurance Process Co-Insurance Your share of the costs of a covered health care service, calculated as a percentage (for example, 20 percent) of the allowed amount for the service. You pay coinsurance plus any deductible you owe. Example: If the health insurance plan's allowed amount for an office visit is $100, and you have met your deductible for the year, your coinsurance payment of 20 percent would be $20. The health plan pays the rest of the allowed amount. 8
Health Insurance Process Co-Payment A fixed amount you pay for a covered health care service, usually when you receive the service. Example: When you have a doctor appointment, you pay $45. 9
Health Insurance Process When do I contact Covered California and/or the Health Insurance Company? Covered California Changes in application information Income Name Address Phone Number Dependents Health Insurance Company Primary Care Provider Payments Claims What your benefits cover 10
What is included in my health plan? Health plans = a package of health benefits and services. Cost will depend on your insurance plan 11
What are Preventive Services? Services or measures taken to prevent diseases instead of curing or treating them and to maintain proper health What is covered: Yearly physical checkups Well-woman visits Mammograms Pap smears Immunization shots Flu shots Hep A & B Preventive services are FREE! Your doctor should NOT charge you for these services! 12
Why are Preventive Services important? Preventing an illness is much easier and less expensive than managing or curing one after it has begun Reduce or eliminate risks for chronic conditions Early prevention and diagnosis is key! Even if you do not feel sick, symptoms may be lurking inside your body Need to do early preventive screenings and tests to detect the early warning signs Remember: Preventive services are FREE! Your doctor should NOT charge you for these services! 13
How to get health services? Make sure you have the correct doctor you want on your insurance card. The doctor listed on your card is called your primary care provider. Call your doctor s office to schedule an office. 14
What services can my doctor provide? Depends on your plan PPO Don t have to see innetwork doctor for insurance company to pay Insurance company will pay more of the costs of in-network doctors Can go to a Primary Care Provider or a specialist on your own HMO Must see in-network doctor for insurance company to pay Must have a Primary Care Provider that will provide general health services, such annual exams & assess your health problems Only your PCP can refer you to see a specialist EPO Must see in-network doctor for insurance company to pay Can go to a Primary Care Provider or a specialist on your own A specialist, is a expert in a medical practice such as the heart, lung, brain, skin, etc. 15
How the ACA Helps You Appeal Health Plan Decisions New standardized legal protections If you and your health plan disagree about your care or coverage, you have new rights to help you challenge their decision These protections apply only to health plans set up after March 23, 2010 Medi-Cal and Medicare already follow these appeal rules
Your Appeal Rights You have a right to appeal if your plan: Refuses to give you health care Refuses to pay for your health care Cancels your insurance Your plan must give you a notice explaining: Why they made the decision How you can appeal the decision How long you have to file your appeal
Language Access In CA, if you do not speak English and need help to explain your side to the health plan: You have the right to an interpreter You may receive written information about appeal rights in your language Depending on the language Call your health plan to request these language services
Appeal Process: Level 1 Appeal Someone who works for your health plan will review the plan s decision to see if it is correct Your health plan must let you: Review your file See the information the plan used to make its decision Give new or missing information you think is important and may help the reviewer change the plan s decision You have a legal right to review your file. Your plan cannot charge you for this.
Level 1 Appeal If you win, you will get the coverage or service you asked for If you lose, your plan must explain in writing why they denied your appeal Your health plan must decide within: 72 hours for urgent care 30 days for non-urgent care you are waiting for 60 days for services already received but your health plan refused to pay for
Appeal Process: Level 2 Appeal You may have the right to appeal to an independent reviewer, if you lose on Level 1 appeal If HMO, contact California Department of Managed Health Care If PPO, contact California Department of Insurance For Medi-Cal, you can appeal beyond DMHC and request a court hearing with an administrative judge.
Resources Covered California www.coveredca.com 888-975-1142 Medi-Cal and Medi-Cal Managed Care www.dpssbenefits.lacounty.gov/ybn/index.html 888-442-2273 Asian Americans Advancing Justice - Los Angeles www.advancingjustice-la.org 213-977-7500 213-241-0284 (Connie Lo) Chinatown Service Center 213-808-1700 22
Health Plan Problems For HMOs: 888-466-2219 California Department of Managed Health Care (DMHC) For PPOs: 800-927-4357 California Department of Insurance (CDI) Legal Assistance Private Health Plan Problems: Health Consumer Center of Los Angeles: 800-896-3203 Medi-Cal Managed Care Health Plan Problems: Legal Aid Foundation of Los Angeles: 323-801-7912
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