Medical insurance (also known as health or accident insurance) helps pay for your health care costs, such as visits to the doctor and prescription drugs. You typically pay a monthly premium (the amount you must pay to have coverage) and then your insurance company covers the rest of your health care costs up to a certain limit. Your policy might have a deductible (the amount you must pay out of pocket before your insurance begins to pay) and copays or coinsurance (a percentage of the cost that you must pay after you meet your deductible).
If you are uninsured, you are at higher risk of medical problems and of dying because you are less likely to receive health care services when needed. In fact, research shows that the uninsured are more likely to die in hospital from conditions such as acute coronary syndrome or stroke than those with private or public health insurance (Box 3.2).
Many medical insurance plans only cover pre-hospitalisation expenses and post-hospitalisation expenses. However, you can choose to take a plan that offers both types of benefits or a combination of the two depending on your needs and budget.
Individual and family health insurance plans can be purchased on the exchanges set up by the ACA, or directly from private insurers. These plans can be more expensive than those offered through an employer or the government, but they often offer more flexibility in choosing healthcare providers. You can also find a plan that meets your needs by looking for a specific type of service or condition.
In addition, you can select a provider from a Preferred Provider Network (PPO) or an Exclusive Provider Network (EPO). You will generally pay less if you use healthcare providers in your plan’s network. Some plans may also have a tier system where you pay different amounts to see providers in each tier.
The Affordable Care Act requires that most non-grandfathered individual and small group major medical insurance plans cover preventive services without requiring you to pay out of pocket. These include screenings for cancer, diabetes, and high blood pressure. It also requires that all non-grandfathered plans have no lifetime limits on essential health benefits.
If you are dissatisfied with your health insurance, talk with your doctor or call your health insurer. If you can’t resolve your complaint with your health insurer, you may be able to file a grievance or appeal. If you’re in a life-threatening situation, you can ask your health insurer to review your case quickly by calling for an Expedited Review. If you still aren’t satisfied with the outcome, you can contact the California Department of Insurance (CDI). Learn more about consumer rights and protections in our California guide to health insurance.