Frequently Asked Questions

The Health Insurance Marketplace (also known as the Health Insurance Exchange) is a government-run or state-based online platform where individuals, families, and small businesses can compare and purchase health insurance plans that meet the requirements of the Affordable Care Act (ACA). The Covered California Marketplace helps people find affordable health insurance and offers subsidies to those who qualify based on income.

Individual health insurance covers only one person—the policyholder. It provides benefits specifically for the insured individual, including medical, hospital, and preventive services. Family health insurance covers more than one person—typically the policyholder, their spouse or partner, and dependent children (up to a certain age, often 26 in the U.S.). Family plans provide coverage for multiple family members under a single policy. Individual plans are generally less expensive than family plans.

There are several types of health insurance plans, including:

• Health Maintenance Organization (HMO): Requires members to choose a primary care physician (PCP) and get referrals for specialists.
• Preferred Provider Organization (PPO): Offers more flexibility to see specialists without referrals, but comes with higher premiums.
• Exclusive Provider Organization (EPO): Similar to PPOs but you must use the plan’s network of doctors and hospitals, except in emergencies.
• Point of Service (POS): Combines features of HMO and PPO plans, allowing some out-of-network care.
• High Deductible Health Plan (HDHP): Has higher deductibles but lower premiums, often paired with Health Savings Accounts (HSAs).
• Catastrophic Health Insurance: Offers low premiums but high deductibles; ideal for young and healthy individuals for worst-case scenarios.

The Affordable Care Act (ACA), also known as Obamacare, is a comprehensive healthcare reform law enacted in the United States in 2010. Its main goal is to make healthcare more affordable and accessible for Americans, especially those who were previously uninsured or underinsured. Covered California is California’s ACA Health Insurance Marketplace.

Health insurance helps protect you from high medical costs. Without insurance, medical expenses like surgeries, hospital stays, or long-term treatments could be financially overwhelming. Health insurance also provides access to routine and preventive care, helping to manage and prevent serious health issues. It is also against the law in California to go without health insurance and you could pay a tax penalty.

A deductible is the amount you pay out of pocket for healthcare services before your insurance starts to pay. For example, if your plan has a $1,000 deductible, you must pay the first $1,000 of your medical costs, and after that, the insurance will begin to cover a portion of your expenses.

A co-pay is a fixed amount you pay for a healthcare service (e.g., $20 for a doctor visit), usually at the time of service.

Co-insurance is the percentage of costs you pay after you’ve met your deductible. For example, you may pay 20% of the cost of a procedure while the insurance pays the remaining 80%.

An out-of-pocket maximum is the maximum amount you will have to pay for covered healthcare services in a plan year. Once you reach this limit, your insurance will cover 100% of any additional covered expenses for the rest of the year.

An in-network provider is a healthcare provider or facility that has a contract with your insurance company to provide services at reduced rates. Using in-network providers typically results in lower costs for you. Out-of-network refers to healthcare providers or facilities that do not have a contract with your insurance company. If you receive care from out-of-network providers, you may face higher costs, and in some cases, the insurance may not cover the expense at all.

A pre-existing condition refers to any health condition you had before enrolling in a health insurance plan, such as asthma, diabetes, or cancer. Under the Affordable Care Act (ACA), insurers cannot deny coverage or charge higher premiums based on pre-existing conditions.

You can find out for free if you qualify for free or low-cost health insurance in California by calling our friendly, bilingual Acceptance Insurance agents. We’ll help you make sense of confusing health insurance coverage. Just call us at 877-423-5651 to find out and for help.