choose from. Whether you are self-employed, or looking for coverage over and above what your employer currently
offers, there is a plan that will likely meet your needs. Federal regulations require that health plans operating
under the Affordable Care Act (ACA) meet certain access requirements. In California, those requirements include
timely access to healthcare providers, as well as geographic access standards.
Here is a general guide to individual health insurance that you can refer to when choosing a plan. And do not
forget these important dates regarding open enrollment for 2016.
Provider Networks
When selecting a health insurance plan, it is important to verify the plan's provider network of doctors,
hospitals, nurse practitioners, therapists, and other health care providers. It is equally important to understand
what is not covered as well. Understanding your plan's provider network helps you save money, receive better care,
avoid unexpected fees and costs, and be happier with the care you receive.
Out-of-Network Care
You are not restricted to health care providers in your network, but should you decide to use one outside of your
network, health insurance will cover less resulting in a higher out-of-pocket cost for you, except in the case of
emergencies.
Provider No Longer in Network
If your health care provider leaves your network, you will generally need to find a new doctor inside the network,
and most plans will assist you in doing so. As a rule, a health plan's continuity of care policy allows a patient
to continue care with a doctor no longer in the network for a certain period of time at the lower cost-sharing
rate.
Cost-Sharing Requirements
Each plan has different cost-sharing requirements. Typically, your overall share of costs is a combination of the
premiums you pay plus any other co-payments, co-insurance or deductibles for which you are financially
responsible.
How to Find a Doctor
In most cases, the plan you choose will have a list of doctors who accept your insurance. The Medical Board of
California offers some great tips on choosing a doctor:
Ask friends, family or co-workers about physicians they like.
Ask your county medical society or association for names of physicians in your area.
Once you have some names, call and ask if the doctor is accepting new patients and whether they accept your
insurance plan.
Check with the Medical Board to verify the physician has a current California license.
Meet with the physician and consider having a physical done to determine if this is the doctor for you and your
family.
Selecting a Hospital
When you undergo treatment in a hospital or other facility, ask to have any services performed by in-network
providers. Your physician may decide which hospital is appropriate for your care, but you can still check the
hospital's California HealthCare Foundation rating by visiting www.calqualitycare.org.
This guide to individual health insurance is far from complete. For more information and a more comprehensive
glossary of insurance terms and other marketplace information, visit www.healthcare.gov.
Learn More
From preventative services to out-of-pocket maximums, understanding your individual health insurance plan options
can be a confusing - and frustrating - endeavor. A health insurance agent is one of your best resources for
information on coverage that meets your unique needs.
This article originally appeared on Navigate Health Insurance's blog.
As certified Covered California insurance agents, we can help you navigate this complex process. Contact Navigate
Health Insurance today at (925) 788-6824 to discuss your health insurance options. We look forward to serving you!
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