Health Insurance FAQs
Monday, January 8, 2024

The new year is a good time to check on any changes to your health insurance and ensure you know how to make the most out of your benefits. Below are some commonly asked questions about insurance and links to resources to get more information.

Q: What kind of health insurance am I eligible for?

Many people qualify for health insurance through their employer. If you do not have health insurance through work, then you have several other options to explore:

  1. Purchase insurance privately – you can go through an insurance broker to find the best plan for you. However, it is a good idea to first see if you qualify for any subsidies through Covered California (a part of the Affordable Care Act).
  2. If you are low-income, you may qualify for Medi-Cal, California’s version of Medicaid, for free or very low-cost healthcare coverage. You may apply through Covered California’s website or you may apply directly at BenefitsCal.
  3. If you are 65 or older, or if you have a permanent disability, End-Stage Renal Disease or ALS, you may qualify for Medicare. For more information about Medicare, please contact Los Angeles County’s Health Insurance Counseling and Advocacy Program (HICAP) at the Center for Healthcare Rights or visit the Medicare website.
  4. If you are under 26 years of age, you may be able to remain on your parent’s health insurance.

Q: What’s the difference between premiums, deductibles and copayment/coinsurance?

  • A premium is the monthly or annual amount you need to pay for your health insurance, regardless of whether you use it (if you receive Medi-Cal, you won’t usually have a premium).
  • A deductible is the amount of out-of-pocket costs you need to pay before your health insurance coverage begins (not all plans have deductibles).
  • Coinsurance or copayments refer to the amount you are responsible for at the time of an appointment/hospital visit/etc. or for a prescription. For example, you may have to pay a $20 copayment every time you go to the doctor. Coinsurance is like a copayment but instead requires you to pay a certain percentage of the total cost of the medical service, as opposed to a fixed dollar amount each time. Annual wellness visits and some other types of preventative medical care are typically free.
  • Out-of-pocket maximum is the absolute maximum amount you would pay out-of-pocket over the course of the year – after you reach that, your care is covered 100%.

Q: What is an HMO? A PPO?

  • An HMO (“Health Maintenance Organization”) generally offers more affordable care but you will have to exclusively use “in network” providers and need a referral from a Primary Care Provider (PCP) before you see specialists.
  • A PPO (“Preferred Provider Organization”) generally costs more than an HMO but allows you the freedom of seeing an array of providers, whether they are “in-network” or not, and allows you to see specialists without a referral.

Q: How do I go about getting medical care?

Start by establishing care with a Primary Care Provider (PCP). While having a PCP may not be required for a PPO plan, it is a good idea to have a primary doctor to oversee your care. If you have an HMO, you will need to visit their website or call their customer service line to find an in-network PCP that is taking new patients.

Your annual wellness visit is typically free, regardless of the type of insurance you have.

Q: How do I get connected with mental health support?

Through the Affordable Care Act, mental health and substance use services are covered. If you have an HMO health plan, start by visiting their website or calling their customer care line for in-network providers. Refer to our “How to Find a Therapist” FAQ for more information.

Q: What about vision and dental services?

Vision and dental may or may not be a part of your health insurance. For example, Medi-Cal includes vision and dental, but Medicare does not, unless you opt to purchase a Medicare Advantage plan. If your plan doesn’t have the vision and dental you are looking for, you can typically purchase a plan privately.

For any general questions related to accessing healthcare coverage, please visit our website or contact our Assistance, Information and Referral Line at 310-374-3426, Option 1.