Compare CA health insurance rates side-by-side and apply online for California health insurance from your home or office.
A
Access for Infants and Mothers Program (AIM)
Provides low cost health insurance coverage to uninsured, middle income pregnant women in California. (See Healthy Families regarding low-cost coverage for newborns, children and teens.)
Actuary
A mathematician in the insurance field. Responsible for calculating health insurance premiums, developing plans and defining underwriting risk.
Acute Care Facility
One step below a hospital, an acute care facility gives advanced medical and nursing services to bring you and your family back to health.
Adverse Selection
The tendency for people to avoid buying health insurance unless they are sure they will benefit from it. In a health insurance context, this means that people with chronic health problems are more likely to seek health insurance coverage than healthier people.
Agent
A licensed California insurance agent represents several insurance companies and sells their products.
Ambulatory Surgical Facility
Provides surgical services on an outpatient basis for patients who do not need to occupy an inpatient, acute care hospital bed.
Approved Services
Services and supplies covered under a California health insurance agreement, contract, or certificate within the benefit period.
Assignment
Your signed authorization to your doctor or hospital (medical provider) assigning payment to be made directly to them for your medical treatment.
Assisted Living
(See "board and care facility")
B
Benefit
Reimbursement for covered medical expenses as specified in your California health insurance plan.
Benefit Period
The amount of time your California health insurance coverage is effective.
Benefits
Medically necessary services and supplies that qualify for settlement under a health insurance agreement.
Board and Care Facility (Long Term)
A board and care facility offers no nursing services. It is designed for people who are unable to take care of their day-to-day feeding, hygiene, and/or ambulatory needs. Sometimes called an "assisted living facility," their orientation is for provision of service over the "long term."
Brand-Name Drug
Prescription drug which is marketed with a specific brand name by the company that manufactures it. May cost insured individuals a higher co-pay than generic drugs on some CA health insurance plans. (see "generic.")
Broker
A person licensed by the State to sell California health insurance coverage with multiple health plans or insurers. The broker represents you and not the insurance companies. The broker helps you shop for the best policy. California law does not require an individual to be licensed to sell HMO products in California.
C
Capitation
A flat per patient fee paid to providers no matter how many services they have provided.
Carrier
Insurance company or HMO insuring the California health insurance plan.
Case Management
Identifying an individual patient’s needs and problems, and devising a method to meet those appropriately and cost-effectively. Consultation with medical professionals helps the patient take advantage of care appropriate for the patient’s condition rather than a fixed set of treatments and procedures.
Certificate Booklet
The health insurance plan agreement. A printed description of the benefits and coverage provisions intended to explain the contractual arrangement between the California health insurance carrier and the insured group or individual. May also be referred to as a health insurance policy booklet.
Certificate of Coverage
A document issued to a member of a California group health insurance plan showing evidence of participation in the health insurance plan.
Certificate of Creditable Coverage
A written statement from your prior health insurance company or health plan documenting the length of time you were covered by that particular health insurance plan.
Chronic Condition
A medical condition or disease that goes on for a long period of time. Examples are diabetes and cystic fibrosis.
Claim
A notification to your health insurance company that payment is due under the health plan policy provisions.
COBRA and Cal-COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA) is federal law that extends your current group health insurance when you experience a qualifying event such as termination of employment or reduction of hours to part-time status. Applies only to employer groups with 20 or more employees.
Cal-COBRA is California law that has similar provisions to federal COBRA. Cal-COBRA law applies to group health insurance policies in force with 2-19 employees covered.
Coinsurance
Once you have met your health insurance plan deductible, you pay coinsurance for additional medical care. It is a percentage of the billed charge. For example, your California health insurance company might pay 80%, and then you would pay 20%. It is similar to a co-pay, but is a percentage instead of a dollar amount.
Co-Payment
A fixed dollar amount you pay to your provider for covered health care services. For example, $20 for an office visit or $15 for a prescription drug. It is similar to coinsurance, but it is a dollar amount instead of a percentage of the charges.
Coordination of Benefits (COB)
Applies when an individual is covered by more than one individual or group health insurance policy providing benefits for like services. COB is a method of limiting insurance settlement to no more than 100 percent of one health insurance carrier’s settlement arrangement.
Coverage
The scope of protection provided by a California health insurance contract which includes any of the listed benefits in the health insurance policy.
Covered Charge
The amount a provider bills the health insurance plan for a covered service.
Covered Services
Medically necessary procedures, services, or supplies listed in the health plan member's benefits certificate.
Creditable Coverage or Prior Qualifying Coverage
The number of months you had health insurance in place before your current or new health insurance policy became effective. Creditable coverage must be counted towards any pre-existing condition exclusion in either an individual or group California health insurance policy, subject to certain guidelines.
Custodial Care
Assistance in meeting daily living activities not requiring the continued attention and assistance of licensed medical or trained paramedical personnel. Some examples include assistance in walking and getting in and out of bed; aid in bathing, dressing, feeding; preparation of special diets; and supervision of medication which can usually be self administered.
D
Deductible
The amount you must pay for medical services each year before your California health insurance plan begins paying co-insurance benefits.
Dependents
Usually the spouse and unmarried children (adopted, step or natural) of an insured individual or employee.
Drug Formulary
A list of drugs that your California health insurance plan will pay for. Drugs that are not on the health plan formulary ("off-formulary") are sometimes covered but are more expensive (see "excluded drugs"). To you, the cheapest drugs are generic drugs that are on the health plan formulary, and the most expensive drugs are name-brand drugs that are off-formulary.
Effective Date
The date upon which contracted health insurance benefits become available.
Elimination Period
(see "pre-existing condition") A period of time before health insurance benefits are payable.
ERISA
Stands for the Employee Retirement Income Security Act (1974). Administered by the U.S. Department of Labor, Employee Benefits Security Administration. ERISA regulates employer sponsored pension and health insurance plans (self-insured health plans) for employees.
Exclusive Provider Organization (EPO)
A health insurance plan similar to an HMO in which members must receive services from participating providers or benefits are denied.
Excluded Drugs
Prescription or non-prescription drugs not covered by the California health insurance policy.
Exclusions and/or Limitations
Conditions or circumstances spelled out in a health insurance policy which limit or exclude the health plan coverage benefits. It is important to read all exclusion, limitation, and reduction clauses in your health insurance policy or certificate of coverage to determine which expenses are not covered by the health insurance plan.
Experimental and/or Investigational Medical Services
A drug, device, procedure, treatment plan, or other therapy which is currently not within the accepted standards of medical care.
Explanation of Health Care Benefits
Explanation of Health Care Benefits( EOB) is a statement a health insurance plan member receives which outlines how the CA health insurance plan benefits are applied to a submitted claim.
F
Facility
A licensed, certified, and/or accredited facility which provides inpatient and outpatient services. Examples of facilities are hospitals, nursing facilities, and ambulatory surgical facilities.
Family Coverage
Benefits are allowed for the California health insurance plan enrollee and eligible family members.
Fee-for-Service
A system in which you pay the provider for each single service or procedure.
Formulary
(see "drug formulary")
G
Gatekeeper
A primary care provider who initially assesses a patient’s condition and needs and refers the person to the appropriate treatment or provider.
Generic Drug
The chemical equivalent to a "brand name drug." These drugs cost less, and the savings is passed onto health insurance plan members in the form of a lower co-pay.
Grace Period
A specified period immediately following the premium due date during which a payment can be made to continue a health insurance policy in force without interruption. This applies only to Life insurance and Health insurance policies. Check your policy to be sure that a grace period is offered and how many days, if any, are allowed.
Group Health Insurance Plan
When groups of individuals are covered under one insurance contract. Usually people are offered California group health plans by their employers (see "individual health plan").
Guaranteed Issue
A California health insurance policy that must be issued regardless of any pre-existing medical condition.
H
Health Care Plan
A broad term which refers to systems of organization and delivery of health care. Common examples are (a) a pre-paid hospital and medical plan such as Health Maintenance Organization (HMO); or (b) a health insurance policy requiring that patients use preferred providers (PPOs). Often used to distinguish managed care or integrated service benefits from fee-for-service coverage.
Health Care Provider
Term used to describe a person, organization, or institution that delivers health care services, e.g., a doctor, nurse, practitioner, clinic, or hospital.
Health Insurance Portability and Accountability Act (HIPAA)
In 1996 the federal government passed into law the Health Insurance Portability and Accountability Act (HIPAA). HIPAA law provides eligible individuals who have recently lost their employer sponsored group health insurance plan the opportunity to purchase health insurance coverage even if they have a preexisting health condition.
Health Maintenance Organizations (HMOs or Managed Care)
Membership in a Health Maintenance Organization (HMO) requires plan members to obtain their health care services from doctors and hospitals affiliated with the HMO except in certain emergency situations. It is common practice in HMOs for the California health insurance plan member to choose a primary care physician who treats and directs health care decisions and who coordinates referrals to specialties within the HMO network. HMOs offer access to a comprehensive package of covered health care services in return for a prepaid monthly amount (premium). Most HMOs charge a small copayment depending upon the type of service provided.
Health Savings Account (HSA)
An HSA, or Health Savings Account combines high deductible health insurance with a tax-advantaged medical savings account. Withdrawals used to pay qualified medical expenses, including your health insurance deductible, coinsurance or co-payments are not subject to federal income tax. Money in the savings account rolls over and accumulates year over year if not spent. HSAs are owned by the individual. Funds may be used to pay for qualified medical expenses at any time without federal tax liability. Money in an HSA earns interest and can be directed toward long-term investment vehicles, such as mutual funds, to maximize the future value of your HSA.
Healthy Families Program
The California Healthy Families Program provides low cost health, dental, and vision coverage to children whose parents earn too much to qualify for public assistance, but do not earn enough to purchase comprehensive major medical health insurance coverage for their children.
High-Risk Pool
These state programs offer health insurance coverage to individuals and small groups who have been denied other health insurance coverage or whose medical conditions make premiums prohibitively high. Services are delivered through contracts with health insurance plans.
Home Health Care
Informal custodial care (non-medical care) provided in the patient's home by caregivers or by family and friends. Home health care is not provided by nurses, doctors, or other licensed medical personnel.
Home Medical Equipment, also Durable Medical Equipment
Medical equipment which is durable enough to withstand repeated use; it is primarily and customarily manufactured to serve a medical purpose. Examples include wheelchairs, walkers, and crutches.
Hospice Care
Care given to someone expected to live less than six months due to a terminal disease or condition. Hospice care can be given at home or in a hospice center or a board and care facility.
I
ID Card / Identification Card
Card given to insured individuals which advises medical providers that a patient is covered by a particular California health insurance plan.
Indemnity Insurance Plans
Traditional health insurance plans (not HMOs or PPOs) which permit insured individuals to choose their doctors and hospitals. Insured individuals do not have to choose doctors or hospitals from a specific list of providers. Also called "fee-for-service" health insurance plans.
Independent Medical Review (IMR)
A process where expert medical professionals, who have no relationship to your California health insurance company or health plan, review specific medical decisions made by the health insurance company. California law provides for an Independent Medical Review (IMR) program.
Individual Health Insurance Plan
A form of health insurance designed to cover just one person (and often immediate family members), as opposed to someone covered by a California group health insurance plan (see "group health insurance plan").
Individual Practice Association (IPA)
A type of health maintenance organization in which an association, made up of individual practice physicians, contracts to provide services to the HMO enrollees. The HMO pays the IPA on a capitated basis to provide a defined package of services to its members.
In-Network
Describes a provider or health care facility which is part of a health insurance plan's network. When applicable, insured individuals usually pay less when using an in-network provider.
Insurance Company
A California insurance company must be licensed by the Department of Insurance to sell California health insurance. The insurer issues policies which outline coverage. An insurance policy is a contract between the insured and the insurance company. You pay your premiums to an insurance company. They then pay some or all of your medical provider's bills when you need treatment (see "provider").
L
Lifetime Benefits Maximum
The total dollar amount, number of days, or number of visits allowed for covered services for each person covered under a California health insurance plan certificate or agreement. There can be separate lifetime maximums for different categories of benefits.
Limitations
A restriction on the amount of benefits paid out for a particular covered expense.
Long-Term Care
Long Term Care is the assistance or supervision you may need when you are not able to do some of the basic "activities of daily living" (ADL) like bathing, dressing or moving from a bed to a chair. Examples of conditions in which you might need assistance with ADLs are: injury, illness, advanced age, or mental deterioration.
Long-Term Disability (LTD)
Insurance which pays employees a percentage of monthly earnings in the event of disability.
Managed Care
The coordination of health care services in the attempt to produce high quality health care for the lowest possible cost. Examples are the use of primary care physicians as gatekeepers in HMO plans and pre-certification of care. Managed care generally emphasizes cost control and may provide coverage for preventive medicine. There are restrictions on the types of procedures that can be used for each medical condition. The amounts that can be charged for the procedures are described by the terms and conditions of the health insurance plan.
Major Medical Plan
A high-limit, high deductible California health insurance plan to cover catastrophic illness or injury. Major medical used to be called "catastrophic insurance."
Major Risk Medical Insurance Program (MRMIP)
The Major Risk Medical Insurance Program (MRMIP) offers limited health insurance benefits to California residents who are unable to purchase health insurance due to a preexisting medical condition. If you have a preexisting condition and are not eligible for COBRA, Cal-COBRA, or HIPAA, then you can apply to MRMIP as a last resort to obtain health insurance coverage.
Medically Necessary
A drug, device, procedure, treatment plan, or other therapy that is covered under your health insurance policy and that your doctor, hospital, or provider has determined essential for your medical well-being, specific illness, or underlying condition.
Medi-Cal
Medi-Cal is the name of the Medicaid program in the State of California.
Medicaid
Form of public assistance sponsored jointly by federal and state governments providing medical assistance for eligible persons whose income falls below a certain level. The program was created by the Social Security Act of 1965.
Medicare
Federal government health insurance program established under Title XVIII of the Social Security Act for people age 65 and older and for individuals of any age entitled to monthly disability benefits under the Social Security or Railroad Retirement Program. Medicare also provides benefits for those with chronic renal disease who require hemodialysis or kidney transplant.
Medical Spending Account, also Reimbursement Account
An account into which employees can contribute pre-tax dollars to reimburse health-related expenditures not covered by health insurance. Qualified expenses include copayments and deductibles as well as items like contact lenses, prescription drugs, and long-term care. Money left in the account at the end of the year is forfeited.
Medical Underwriting
Process by which the health status of individuals and groups is used to determine whether to provide California health insurance coverage, under what conditions, and at what rate to charge.
Multiple Employer Trust (MET)
An arrangement created to obtain health insurance and other benefits for participating employer groups. Small employers can pool their contributions to receive the advantages of large group insurance underwriting.
Name-Brand Drug
A drug sold under a name-brand, and covered by original patents. Name-brand drugs are more expensive than generic drugs, and you usually have a higher co-pay for them than generics (see "generic drugs").
Network
A group of doctors, hospitals and other providers contracted to provide services to insured individuals for less than their usual fees. Provider networks can cover large geographic markets and/or a wide range of health care services. If a California health insurance plan uses a preferred provider network, insured individuals typically pay less for using a network provider.
Non-Network, Non-Participating Facility
A facility not in the chosen network and which does not participate with a given California health insurance plan.
Non-Network, Non-Participating Provider
A provider who is not in the chosen provider network and who does not participate with a given health insurance plan.
Nursing Facility
A facility which provides continuous skilled nursing services as ordered and certified by an attending physician. A registered nurse (R.N.) must supervise services and supplies on a 24-hour basis. A nursing facility must also be licensed under the laws of the state in which the facility is located.
O
Open Enrollment
The time (usually a preset two-week or one-month period annually) when you can change health insurance plans under your employer's California group health insurance plan.
Over-the-Counter Drug
You don't need a prescription to obtain over-the-counter drugs.
Out-of-Network
Describes a provider or health care facility which is not part of a California health insurance plan's network. Insured individuals usually pay more when using an out-of-network provider, if the health insurance plan uses a network.
Out-of-Pocket
The amount of money you pay for medical services after your health insurance plan has paid its contribution.
Out-of-Pocket Maximum
The most an insured individual will have to pay in a year for deductibles and coinsurance for covered California health insurance benefits.
Outpatient Services
Treatment and care received in a practitioner’s office, the home, or the outpatient department of a hospital or ambulatory surgery center.
P
Participating Facility
A hospital or other health care facility that participates with a California health insurance plan network.
Participating Provider
A provider who participates with a California health insurance plan network
Plan Administration
Overseeing the details and routine activities of installing and running a health insurance plan, such as answering questions, enrolling new individuals for health insurance coverage, billing and collecting health insurance premiums, etc.
Point-of-Service (POS)
A Point-of-Service (POS) plan is a managed care health insurance plan similar to an HMO. With POS, the patient has a single primary care provider, but that provider can make referrals to providers both in and out-of-network. The health plan covers in-network providers at a favorable rate, but the patient will be responsible for higher out-of-pocket costs if they use an out-of-network physician.
Policy
The written contract between an individual or group policyholder and a health insurance company. The policy outlines the duties, obligations, and responsibilities of both the policyholder and the health insurance company. A policy may include any application, endorsement, certificate, or any other document that can describe, limit, or exclude health coverage benefits under the policy.
Portability
The ability to purchase California individual health insurance or change jobs without being denied coverage because of a pre-existing condition.
Practitioner
Any health care professional recognized by a health insurance company as licensed and/or accredited to provide covered services. Examples include certified nurse, anesthetists, chiropractors, doctors of medicine, doctors of osteopathy, oral surgeons, physical therapists, and podiatrists.
Pre-Authorization or Pre-Certification
Some health insurance companies require pre-admission review and approval of appropriateness and medical necessity of hospitalization, surgery, or other medical treatment.
Pre-Existing Condition
An illness, injury or condition for which the insured individual received medical advice, treatment, services or supplies; had diagnostic tests done or recommended; had medicines prescribed or recommended; or had symptoms of typically within 6 to12 months (time periods may vary depending on state laws) prior to the effective date of health insurance coverage. Most California health insurance plans have a pre-existing condition clause detailing under what conditions medical expenses related to a pre-existing condition are covered.
Preferred Provider Organizations (PPOs)
A Preferred Provider Organization (PPO) is the form of managed care which typically allows you to see any doctor at any time. A PPO negotiates discounts with doctors, hospitals and other providers, who then become part of the PPO network. These in-network healthcare providers have been contracted to provide services to the health insurance plan's members at a discounted rate. When you see a physician out-of-network, you usually still receive coverage but at a higher cost to you.
Premium
The payments you pay to a health insurance company for California health insurance coverage (see "rating factors").
Prescription Drug
You must have a doctor's prescription to receive a prescription drug.
Preventive Medicine
Health care which focuses on wellness, health promotion, and other activities that reduce the likelihood of illness or injury. Examples: Annual physical exam, PAP Smear, cholesterol screening, mammography, infant vaccination, etc.
Primary Care
Health care typically rendered by general practitioners, family physicians, internists, obstetricians, pediatricians, and some mid-level practitioners. This type of care emphasizes the patient’s general health needs as opposed to a specialized or fragmented approach to medical care. The care is usually rendered in an outpatient setting - in a doctor’s office or hospital.
Primary Care Physician (PCP)
A health care professional who acts as a member’s personal health care manager. The PCP evaluates a patient’s medical condition and either treats the condition or coordinates required health care services. In an HMO, you must receive a referral from your PCP to see a specialist if you need to see one.
Prior Approval
A notification requirement for certain elective medical procedures such as cosmetic surgery. Receiving written prior approval will ensure receipt of full benefits.
Provider
Any person or entity providing health care services or prescription drugs, including hospitals, physicians, pharmacies, chiropractors, home health agencies, nursing homes, etc. Usually licensed by the state. (see "insurance company").
Rating Factors
California health insurance premiums are calculated using many rating factors. Rating factors can include:
• Age: the older you are, the more you might pay.
• Health: the poorer your health, the more you might pay.
• Chronic conditions: having one or more chronic or existing conditions can increase your premium.
• Smoking/alcohol use: some companies charge more if you use tobacco or alcohol.
• Gender: some health insurance plans charge more depending upon your gender.
• Geographic region: California health insurance companies break-down coverage areas into regions. Which region you live in
can affect your premium.
Referral
Within many managed care health plans, a referral from your primary care doctor is required to see a specialist or obtain certain services. If you do not get a referral first, the plan may not pay for your care.
Respite Care
Rest and relief help for families caring for terminally ill patients.
Rider
A modification to a Certificate of Insurance policy regarding clauses and provisions of a policy. A rider usually adds or excludes coverage.
Risk
Uncertainty of financial loss.
Risk Pools
Programs created by state legislatures for people who cannot get health insurance in the private market. Funding for the pool is subsidized through assessments from health insurance companies or through government revenues.
S
Short-Term Medical Health Insurance
Temporary health insurance coverage for an individual for a short period of time, usually from 30 days to six months.
Single Health Insurance Coverage
Coverage for the health insurance plan member only.
Skilled Nursing Facility (SNF)
Often called a "SNF." A SNF provides medical care under the supervision of a medical professional or technician, and dispenses medications, performs diagnostics, and can do minor surgery.
Small Employer
In California's insurance code, a small employer is anyone who employs from 2-50 people. The employer(s) can be included in this number. . The definition of small employer group may vary between states.
State Mandated Benefits
State laws which require health insurance plans to cover specified health services or for services from certain health care providers. ERISA exempts self-funded insurers from mandated benefits.
Stop-Loss
The dollar amount of claims filed for eligible expenses at which the California health insurance plan begins to pay at 100% per insured individual. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.
T
Third Party Administrator (TPA)
An organization responsible for marketing and administering small group and individual health plans. This includes collecting premiums, paying claims, providing administrative services, promoting products, and managing other functions related to the operation of health insurance. The TPA is not the policyholder or the insurer.
Third-Party Payer
Anyone who pays for health care other than you. Usually your insurance company. When an insurer contracts with an entity to pay on their behalf. The federal government is a third-party payer under Medicare.
Two-Person Coverage
Health Insurance coverage for a plan member, plus the member’s spouse or dependent child.
U
Underwriter
Entity that assumes responsibility for the risk, issues insurance policies and receives premiums.
Usual and Customary Charges (UCC)
The amount that your health insurance company determines is the normal payment range for a specific medical procedure performed within a given geographic area. If the charges you submit to your health insurance company are higher than what is considered normal for the covered health care services, then your health insurance company may not allow the full amount charged to you.
Utilization Review
Insurance companies and hospitals watch their costs and quality by having medical personnel review selected medical cases. They look at the types and frequency of medical services given and the charges associated with them.
Waiting Period
A period of time which must pass before some or all of your California health insurance benefits begin.
Waiver of Coverage
A section on the enrollment form which states that an employee was offered California health insurance coverage but opted to waive this coverage.
Well-Child Care
Care given to children typically during the first six years of their lives. Services may include age-appropriate pediatric preventive services, as defined by current recommendations for preventive pediatric health care of the American Academy of Pediatrics. Recommended services may include a medical history and complete physical examination, as well as developmental assessment, immunizations, and laboratory services such as screening for lead exposure.
Workers' Compensation Insurance
Insurance coverage for work-related illness and injury. All states require employers to carry this insurance.
