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CREBP Group Program Information Affiliate, Corporate, and Realtor© Association Members can choose from CREBP packages with more than 60+ Anthem Blue Cross® Group Plan Options and more than 20+ Kaiser® Group Plan Options. These plan options are exclusively available to members of Local Real Estate Associations in California. New Association Members are immediately eligible on the 1st of the month following their membership. CREBP Benefit Package w/Anthem Blue Cross® Medical Includes Anthem Blue Cross Medical Plan, New Dental Choice Special Dental Plan, Mutual Of Omaha Guaranteed Issue Group Life Insurance with AD&D, Vision Plan of America, and Admin Fee ​ ​ Find My Plan CREBPT Benefit Package w/Kaiser® Medical Includes Kaiser Medical Plan, New Dental Choice Special Dental Plan, Mutual Of Omaha Guaranteed Issue Group Life Insurance with AD&D, Vision Plan of America and Admin Fee ​ Find My Plan Anthem Blue Cross Anthem Blue Cross understands that our health care needs connect us to each other. What we all do impacts those around us. So, Anthem is dedicated to delivering better care to our members, providing greater value to our customers and helping improve the health of our communities. NOTE: Anthem’s network of PPO and HMO providers provides access to the largest number of health professionals. Kaiser Founded in 1945, Kaiser Permanente has a mission to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Your care team works with you to give you the care you need, when you need it — and you get convenient resources to stay in control of your plan and your health care including on-line access to doctors and one-stop care at Kaiser facilities for medical, testing and pharmacy needs. Why do you need health coverage? Protection from the unexpected Being healthy is easier with preventive care Required by the California Individual Mandate as of 2020 Why should you get a CREBP health plan with Anthem Blue Cross® or Kaiser®? Experience you can count on Health care plans that fit the way you live Online tools to help manage your health care Telemedicine services available 24/7.. How to choose the right health insurance plan for you Understand your health care needs Compare options Select a plan and enroll

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Privacy Policy Your privacy is important to us. We will not share your email address with third parties without your consent. We may send to you email requests to complete, support and analyze your business transactions with The Benefits Store, Inc. and to comply with any requirements of law. We may also send to you emails as a follow-up to the quote you were given, in response to any questions you might have, to provide information to you about your policy, or to provide you with other information that you may find useful. Our goal is to protect the confidentiality of information that you provide to us. This is how we will do this: ​ Information We Collect: Our company needs information in order to issue to you a policy and to service that policy. The information that we need is not generally available to the public. We collect this information in a number of ways: Information that you give us: When you apply for a policy, we record the information that you give us. We do the same thing when you request a policy change. This information includes: First and Last Name Street and E-mail Address Telephone Number Social Security Number Date of Birth Association Membership Gender Marital Status Dependent Information Prior Medical Insurance Information Medical ID Number ​ Information that we acquire in the course of doing business with you: This is information about your transactions with our company. It may include your insurance coverage, deductibles and rates, premium payments, and claims history. Information we obtain from third parties: We may receive information about your association membership which provides us with your association ID number. ​ Parties To Whom We Disclose Information We disclose this information to third parties only to the extent necessary to issue a policy to you, to service a policy already issued to you, to handle claims under your policy, to provide another service that you requested or to respond to a request from a court or governmental agency. We do not disclose this information to third parties except to the extent described above. This is our company policy. We will not change this policy without giving you advance notice. ​ Confidentiality: We restrict access to information about you to those employees and other parties who need that information to provide products or services to you. Their right to further disclose and use the information is limited by our employee code of conduct and applicable law. ​ Security: We maintain physical and electronic safeguards to guard your personal information against unauthorized disclosure or use. ​ Retention and Disposal of Information: We retain your personal information for the period of time necessary to comply with business and legal requirements and the dispose of it according to our established procedures.

Individual and Family Health Plans Better Health – Better Life Whether you are self-employed, in-between jobs or in need of health insurance coverage Get Quality Health Insurance at a Price You Can Afford! Our online quoting platform helps you shop, compare and select the right health insurance plan for you and your family. Welcome to our Individual and Family Coverage page, where we strive to provide comprehensive healthcare solutions tailored to your unique needs. Whether you're seeking coverage for yourself, your family, or your child, we offer a range of options, including Medicare and child-only coverage, to ensure that you and your loved ones have access to quality care and peace of mind. Individual Coverage Our individual coverage plans are designed to provide personalized healthcare solutions for individuals of all ages and life stages. Whether you're a young adult starting your career, a freelancer, or someone transitioning between jobs, our individual plans offer flexibility, affordability, and comprehensive coverage to meet your healthcare needs. Find My Plan Child Only Coverage We understand that children have unique healthcare needs, which is why we offer child-only coverage plans designed specifically for individuals under the age of 18. Whether you're a parent seeking coverage for your child or a caregiver responsible for a child's health, our child-only plans provide access to pediatric care, preventive services, and specialty care to support your child's growth and development. Find My Plan Family Coverage Family is at the heart of everything we do, which is why we offer family coverage plans designed to protect the health and well-being of your loved ones. Our family plans provide inclusive coverage for you, your spouse or partner, and your children, ensuring that everyone in your family receives the care they need, when they need it. Find My Plan Medicare Coverage For individuals aged 65 and older, as well as those with certain disabilities, Medicare coverage provides essential healthcare benefits and financial protection. Our Medicare plans offer a range of options, including Original Medicare (Parts A and B), Medicare Advantage (Part C), Medicare Prescription Drug Plans (Part D), and supplemental coverage (Medigap), to help you navigate the complexities of Medicare and find the plan that best fits your needs. Find My Plan Why Choose Us At The Benefits Store, we believe that everyone deserves access to quality healthcare, regardless of age, income, or health status. Whether you're seeking individual, family, Medicare, or child-only coverage, we're here to help you find the right plan to meet your needs and protect your health and well-being. Contact us today to learn more and take the first step towards comprehensive healthcare coverage for you and your loved ones. ​ Comprehensive Coverage: Our plans offer a wide range of benefits, including doctor visits, hospital stays, prescription drugs, preventive care, and more. Affordable Options: We understand the importance of affordability, which is why we offer competitive rates and flexible payment options to fit your budget. Exceptional Service: Our dedicated team is committed to providing personalized assistance, answering your questions, and guiding you through the enrollment process with ease and efficiency. Trusted Partnerships: We work with leading healthcare providers and networks to ensure that you have access to high-quality care and services in your area.

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Resource Center The Benefits Store Resource Center is designed to empower you with valuable information and insights on various health-related topics. From wellness tips to navigating insurance options, discover expert articles, guides, and tips on a variety of health topics, from insurance FAQs to wellness advice. Stay informed, make informed decisions and take proactive steps towards a healthier lifestyle. Elevate your wellness journey by tapping into the wealth of comprehensive information waiting for you. How to Pick a Health Plan Medical Condition Resources Professional Resources and Ranking Senior Care and Aging Resources

Medical Conditions Empower your health insurance decisions with our Medical Condition Resources page. Dive into a wealth of information tailored to your needs, offering insights and support for navigating various medical conditions. Our expert-curated resources provide a guide for understanding conditions, treatment options, and insurance considerations. Streamline your search for relevant information, ensuring your health coverage aligns seamlessly with your unique requirements. Explore a specialized hub for California Realtors, offering valuable insights to enhance your health insurance journey. Your path to informed and comprehensive health coverage starts here. Cancer Resources American Cancer Society – Support Programs and Services Cancer Care – Finding Resources in Your Community Cancer.Net – Navigating Cancer Care Cancer Support – Resource Directory National Cancer Institute – Resources Cancer.org Choosing a Doctor and Hospital Cancer.org Choosing Your Treatment Team On Line – Cancer Discussion and Resources Diabetes Resources American Association of Diabetes Educators Centers for Disease – Control and Prevention Diabetes – Self-Management Everyday Health Resources – Diabetes Resource Guide Heart Resources Boston Scientific – Heart Smart Resources Centers for Disease Control – Heart Disease Education Materials for Patients The Heart Foundation – Heart Disease Facts WebMD – Heart Disease Resources WomensHealth.gov – Heart Disease Resources Pregnancy Resources Any Baby Can – Community Resources Care Net Pregnancy Centers – Find a Pregnancy Center US Dept. of Health and Human Services – Health Assistance Programs WebMD – Pregnancy Resources Smoking Cessation Resources American Heart Association 1 – Resources to Help Quit Smoking CDC.gov 1 – Quit Smoking Resources CDC.gov 2 – Tips From Former Smokers Quit Smoking Resources SmokeFree.gov – Free Resources Patient Billing and Claims Advocacy Advocate Connection Directory CA Health Advocates – Medicare Billing and Claims CA Medicare Advocacy Center for Medicare Advocacy Patient Medicare Foundation – Pathways to Medicare and Medicaid Why Do Medical Claims Take Too Long? Why do Insurers take so long to respond?

HOW TO PICK A HEALTH PLAN Navigate the complexities of selecting the ideal health plan with our concise resource page on "How to Pick a Health Plan." Gain expert insights and practical tips for informed decision-making tailored to your unique needs. From understanding coverage options to evaluating costs, trust us to be your go-to destination for streamlined guidance. Your journey to a well-informed health coverage choice begins here. How to Pick a Health Plan CA Dept. of Insurance – Health Resource Guide Health Plan Calculator WebMD Health Insurance Quiz Health Insurance News and Advice Consumer Reports – Guide to Health Insurance US National Library of Medicine Health Topic Resources WebMD Prescription Drugs Best Health Insurance Companies Rankings

Senior Care and Aging Resources Aging Parents Care Guide Aging Parents Help Steps Aging Parents Resource Guide Better Health While Aging CA Dept. of Aging – Resources CA Dept. of Health Care Services – Long Term Care CA Long Term Care – Medicaid Eligibility CA Partnership for Long Term Care – R U Ready Resources Elder Legal Preparation for Aging Parents Care Family Caregiver Services – California Department of Aging HHS.gov – Elder and Caregiver Resources Nursing Home Rankings National Council on Aging – Senior Benefits National Institute on Aging Senior Assisted Living Facilities Finder Senior Living – Home Care Finder MediCal – Medicaid Resources Benefits.gov – CA MediCal-Medicaid CA.gov Dept. of Health Care Services – MediCal CA.gov Dept. of Health Care – MediCAl California Dept. of Social Services – Community Care Covered California – How MediCal works Definition: CA MediCal & MediCaid Eligibility.com – CA MediCal Eligibility – Federal Medicaid Medicare.gov – Nursing Home Comparison and Resources Medicare.Gov – Home Health Comparison and Resources Medicare Resources AARP – Finding Best Doctor and Hospital CA Medicare – Health Assistance Medicare Provider Finder Senior Resources on Aging – Recognizing Fraud Medical & Prescription Discount Savings Medical Expenses (click on “Patient Savings”) Retirement Calculators 10 Best Retirement Calculators Market Watch – Retirement Calculator NERD WALLET RETIREMENT Safer Cars Vehicle Ratings

Disability Insurance Protect one of your most valuable assets, Your Income, with Disability Insurance. Having homeowners protection and auto insurance provides peace of mind if you ever need to file a claim for home damage or a car accident. But, what about the peace of mind in knowing you can continue to pay everyday living expenses if you become too sick or hurt to work? Protect your financial foundation — your income — in the event of a disabling illness or injury with Individual Disability Income (DI) insurance. Insuring your income Protecting your financial security. The premium for an Individual DI policy is typically just 1 to 3% of what you earn — often less than the cost of a monthly date night, buying lunch every day or your monthly technology needs (smartphone, internet and cable service). The Benefit Store offers several Types of Disability Insurance Policies for both individuals and business owners with 10 highly rated carriers. Most policies can be catered to meet your individual needs based on your goals and options desired. Ask us about disability insurance First Name Last Name Email Phone Home Zip Code Message Send me the Monthly Newsletter Send Your data is encrypted with a Comodo SSL Security Certificate Types of Disability Insurance Individual Disability insurance can replace a portion of lost income if you are unable to work due to sickness or injury. It can help you to meet your financial obligations and maintain your current lifestyle. Some of the benefits Individual Disability Insurance include: Monthly Benefit Payments - After an initial waiting period, benefits are paid for each month you can't work through the policy's maximum benefit period Non-cancelable and Guaranteed Renewable Coverage Available - Provided premiums are paid on time, your insurance cannot be canceled or changed. Your coverage or premium rates remain the same from the first premium due date until on or after your 67th birthday. Up to 66% Income Replacement for Individuals - Benefits from your disability policy are paid to you income tax free for the length of any long term or total disability Own Occupation - If you become totally disabled from your occupation and choose to work in another occupation, you’ll receive full benefits, regardless of the income you earn from the other occupation Residual and Recovery Benefit - Pays you when you are partially disabled and not earning 100% of your pre-disability earnings. Your Residual benefit will pay you relative to your loss of income. If you can only earn 50% of your previous income, your residual benefit will be 50% of your disability benefit until you get back to your full income. What Is Health Insurance? Health insurance is a legal agreement between you (or your employer, if you have insurance through work) and an insurance company. The contract states that you pay the insurance company a premium for coverage and the insurer pays for at least a portion of your qualifying medical expenses. Health insurance has a variety of benefits. It can protect you from paying unexpected and expensive medical bills. It also covers essential health benefits, like annual physicals. Most plans also provide free preventative care, like vaccines and screenings. Why Do I Need Health Insurance? Health insurance: How it protects you from health and financial risks No one plans to get sick or hurt, but most people need medical care at some point. Health insurance covers these costs and offers many other important benefits. Health insurance covers essential health benefits critical to maintaining your health and treating illness and accidents. Health insurance protects you from unexpected, high medical costs. You pay less for covered in-network health care, even before you meet your deductible. You get free preventive care, like vaccines, screenings, and some check-ups, even before you meet your deductible. How Does Health Insurance Work? People with health insurance usually pay a health insurance premium for coverage. If you get coverage through an employer, the business will likely deduct your portion of the premium from your paycheck. The premium depends on a few factors, like the plan type and your location. Before you visit a doctor, you should check to see if the provider or medical facility is in your health plan’s network. Providers and hospitals that are considered in network contract with the plan and agree to accept a discounted rate for the services they provide. Health plans pick up more of the health care costs for in-network providers than out-of-network providers, which means lower costs for you if you stay in network. Some health insurance plans, such as health maintenance organization plans, only reimburse you for medical services when you go in-network. Others, like preferred provider organization plans provide limited coverage when you visit an out-of-network provider. Regardless of your plan, you almost always pay less out-of-pocket when you get medical care in-network. After a doctor’s visit, the provider typically submits a claim to your insurance company. Once the health insurance company approves the claim and pays its portion of the costs, the health insurer sends you an Explanation of Benefits (EOB). The EOB details: The services you received. How much your plan covered. What you owe the provider. An EOB also includes information about out-of-pocket costs: Health insurance deductible: Your portion of the annual health care costs before the company begins to kick in money. Coinsurance: Your percentage of health care costs after reaching your deductible, such as 20% of costs paid by you and 80% paid by the insurance company. Annual out-of-pocket maximum: The most you pay out of pocket for in-network care in a year. Your doctor will send you the final bill. On the bill, you can see how much you’re responsible for paying the doctor after your insurance company has paid its portion. The bill will also include instructions for where and how to send the payment. Health Insurance Terms to Know Health insurance is often associated with complicated terminology. Understanding these terms can help when shopping for a health plan and navigating health insurance. Copays A copayment, or copay, is a fixed fee you pay when you receive a specific medical service. Primary care visits often have lower copays than specialists and emergency care. Deductibles Your deductible is the amount you must pay before your health insurance company starts covering your medical expenses. Only in-network provider visits usually count toward your deductible. The deductible resets at the beginning of each year. For example, imagine your health plan has a $1,000 deductible. You would need to spend $1,000 out-of-pocket on qualifying medical expenses before your insurance company starts paying its portion of the bill. Coinsurance Coinsurance is a percentage of each medical bill you must pay after hitting your deductible. Coinsurance is another form of cost-sharing—you pay a certain portion and your insurance company pays the rest. Let’s say your health insurance policy has a 20% coinsurance for outpatient surgeries. You need to have knee surgery and end up with a medical bill of $8,000. In this case, you would pay 20%, which is $1,600, and your insurance company would pay the remainder. Health insurance involves a range of terms and definitions that are important to understand when navigating health coverage. Here are some key terms and their definitions in the context of health insurance: Premium: The amount you pay for your health insurance policy, typically on a monthly basis. Deductible: The amount you must pay out of pocket for covered healthcare services before your insurance plan starts to pay. Copayment (Copay): A fixed amount you pay for specific medical services or prescription drugs, typically at the time of service. Coinsurance: The percentage of costs you share with your insurance company for covered healthcare services, after meeting your deductible. Out-of-Pocket Maximum (OOPM): The most you will have to pay for covered healthcare services in a plan year, including deductibles, copayments, and coinsurance. Network: A group of doctors, hospitals, and other healthcare providers that have agreements with your insurance company to provide services at discounted rates. Out-of-Network: Healthcare providers who do not have agreements with your insurance company and may result in higher out-of-pocket costs. Pre-existing Condition: A health condition or illness that you had before your current health insurance policy went into effect. Open Enrollment Period: A specific timeframe during which individuals can sign up for or make changes to their health insurance plans without a qualifying life event. Health Savings Account (HSA): A tax-advantaged account that allows you to save money for medical expenses when you have a high-deductible health plan. Preferred Provider Organization (PPO): A type of health insurance plan that allows you to visit any healthcare provider, but you'll pay less when using in-network providers. Health Maintenance Organization (HMO): A type of health insurance plan that requires you to choose a primary care physician and obtain referrals for specialist care. Exclusive Provider Organization (EPO): A type of health insurance plan that only covers care from in-network providers, except in emergencies. Marketplace (Exchange): An online platform where individuals and families can compare and purchase health insurance plans, often facilitated by the government. Premium Tax Credit (Subsidy): Financial assistance from the government to help lower-income individuals and families afford health insurance premiums through the marketplace. Medicaid: A government program that provides health insurance for low-income individuals and families. Medicare: A federal health insurance program for individuals aged 65 and older, as well as certain younger individuals with disabilities. Coordinated Care: An approach to healthcare that emphasizes communication and collaboration among healthcare providers to improve the quality and efficiency of care. Essential Health Benefits: A set of healthcare services that must be covered by all insurance plans sold on the health insurance marketplace. Inpatient Care: Medical services received when admitted to a hospital or healthcare facility for an overnight stay. Preventive Services: Healthcare services and screenings aimed at preventing illness or detecting conditions at an early stage. Explanation of Benefits (EOB): A statement from your insurance company that outlines the services provided, the amount billed, the amount covered, and what you owe. These are just a selection of terms commonly used in the realm of health insurance. Understanding these terms can help you make informed decisions about your coverage and navigate the healthcare system more effectively. What Are the Different Types of Health Insurance? There are five common types of health insurance plans. A health insurance plan’s design sets the parameters for how you get care and influences what you pay. Health maintenance organizations (HMOs) A health maintenance organization plan (HMO) plan typically only covers your medical expenses for in-network visits. If you go out-of-network, your insurance company doesn’t cover any portion of the bill. The only exception is emergency care, which is covered in-network and out-of-network. HMO members generally choose a primary care provider who oversees and coordinates their care. If you need to see a specialist, you typically must get a referral from your primary care doctor. Preferred provider organizations (PPOs) Preferred provider organization (PPO) plans are the most common type of health insurance if you get coverage through an employer. PPOs offer more flexibility, such as getting covered for out-of-network care. If you have a PPO and go out of network, you typically pay more than if you stay in the plan’s network. PPOs also don’t require a primary care referral to see a specialist. That flexibility generally comes at a higher cost than an HMO. Exclusive provider organizations (EPOs) Exclusive provider organization (EPO) plans are similar to an HMO, including the need to stay in network to get covered. One difference between an HMO and EPO is that you don’t need to choose a primary care provider in an EPO. You can manage your own care and make appointments with specialists without a referral from your primary care physician. One way an EPO is similar to a PPO is that you don’t need to name a primary care provider. Point-of-service (POS) plans A point-of-service (POS) plan lets you get medical care in-network or out-of-network, but you will pay less if you stay in network. POS plan members are required to work with a primary care provider. Referrals are also required to see a specialist, like an endocrinologist or oncologist. You may also need a referral to see an out-of-network specialist. High-deductible health plans (HDHP) A high-deductible health plan (HDHP) is a health insurance plan with a deductible of at least $1,500 for an individual or $3,000 for a family. Any health plan, like a PPO or HMO, can be an HDHP. One of the biggest benefits of an HDHP is a lower premium. The downside is you pay more out-of-pocket when you need care until you reach the plan’s out-of-pocket maximum. Pro Tip When comparing health insurance costs, look at both premiums and out-of-pocket costs, such as deductible, coinsurance and out-of-pocket maximum. Medicare Medicare is a health insurance available to Americans age 65 and older, people with disabilities and individuals with End-Stage Renal Disease (ESRD). Medicare comes in two forms—Original Medicare and Medicare Advantage. Original Medicare includes Part A (hospital insurance) and Part B (medical insurance), with the option to purchase a separate Part D (prescription drug coverage) plan. Medicare Advantage, also called Medicare Part C, is private health insurance. Medicare Advantage combines Parts A and B along with other coverages, including prescription drugs and benefits not found in Original Medicare, such as vision and dental care. Medicaid and CHIP Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost health insurance to low-income individuals, pregnant women and families. These programs are jointly funded by the federal government and state governments. Each state has its own eligibility requirements for Medicaid and CHIP. These requirements are based on income level and household size. Other factors can influence eligibility, including age, whether you’re pregnant and if you have a disability. You can check your eligibility for these programs on HealthCare.gov. You can apply for Medicaid or CHIP through the marketplace. There is no open enrollment for these programs, so you can enroll at any point during the year. How do I choose the right health insurance plan for my needs? When we’re given a choice about our health care plans, we often choose badly. In one study, more than 80% of the employees at a Fortune 100 company picked the wrong plans, often choosing low-deductible options that ultimately cost them more. Another study found that inertia — sticking with the same plan, rather than evaluating the options each year and choosing a better one — cost workers an average $2,032 annually. These findings shouldn’t surprise anyone who has tried to compare multiple health insurance plans offered by an employer, an Affordable Care Act marketplace or insurers with coverage that supplements Medicare. There are simply too many moving parts: what you pay each month (your premium), how much you have to pay before insurance picks up a larger share of the cost (your deductible), and the limit on how much you’ll pay in a year (your maximum out-of-pocket), for starters. There’s also how much you’ll owe for each doctor’s visit, test or prescription, which could be a flat amount (your co-pay) or a percentage (your co-insurance), or both. These amounts can vary not just by insurance plan, but also by the types of medical service you get, with different amounts for hospital stays, lab work, preventive care and so on. Which prescription drugs are covered varies from plan to plan and from year to year. So does the list of medical providers who are considered “in-network.” But we owe it to our health and wallets to make the best choices we can during open enrollment. The following steps won’t guarantee you’ll pick the best plan, but they may help you avoid the worst. Match your consumption to your deductible Many experts recommend high-deductible plans for healthy people who rarely visit the doctor, since premiums for these plans are lower. But high-deductible plans also can be a good fit for people who need a lot of health care, says Carolyn McClanahan, a physician and certified financial planner in Jacksonville, Florida. Parents of young children or people who have chronic health conditions often spend so much on care that they can easily meet a higher deductible, McClanahan says. Many high-deductible plans (those with deductibles in 2020 of at least $1,400 for individuals or $2,800 for families) qualify for tax-advantaged health savings accounts, as well. These plans aren’t a good fit, however, for people who would put off necessary care rather than pay out of pocket. If you don’t have enough savings to cover medical costs until the deductible is satisfied, consider spending more for a lower-deductible plan. Just don’t pay an extra $500 to lower your deductible by $250, as many people did in that first study. If you’re allowed to choose different deductibles for the same plan, multiply the difference in premiums by 12 to get your yearly cost and compare that to the difference in deductibles. Call your doctors If you have physicians and specialists you prefer, call their offices to ask if they are in the network of the plans you’re considering. It’s important to ask “Are you in network?” rather than “Do you take this insurance?” A provider who’s not in the network may be willing to bill your insurer, but you’ll typically pay a (much) larger share of the cost. Do the ‘worst case scenario’ math Some employers offer software that allows workers to upload their claims history from the past year and uses that to recommend a health care plan. I wish that were available to everyone. The closest I’ve seen is HealthSherpa, which helps people winnow their ACA marketplace options based on how they generally use health care. The plan that may have been a good fit for your past claims, though, may not be the best choice for the future — especially if you become seriously ill or injured. To protect against worst-case scenarios, you also need to consider the “out-of-pocket” limits. These are the maximum amounts you’d have to pay in addition to your premiums. Out-of-pocket limits typically range from $2,000 to $6,000, although there may be different maximums for in-network versus out-of-network costs, and not all policies have these caps. Some plans give you only a small break in premiums while exposing you to much larger potential costs, says Alan Silver, senior director of benefits delivery and administration at Willis Towers Watson, a benefits consultant. Before signing up for any policy, add your annual premiums to the out-of-pocket limit to see the potential costs you could face. If the total scares you, look for a plan with a limit that lets you sleep at night. Pro Tip: If you don’t expect to need much health care in the coming year, a Bronze or Silver plan could be a smart financial choice. But if you have a family, expect to start a family or you would rather pay more upfront and less when you need care, a Gold or Platinum plan would likely be a better decision. Can I keep my current doctor with my new health insurance plan? If you're shopping for health insurance, you can prioritize keeping your doctors and prescriptions. Healthcare.gov, state exchanges, and private exchanges all have tools that can help you check if your doctors and prescriptions are available on a given plan. You can also talk to your doctor directly about which health insurance companies they work with. Health insurance companies contract with networks of providers, and it's possible that your doctor is in a network that works with multiple insurers or is in multiple networks. Depending on their answer, you may have multiple companies that you're able to choose plans from when you start shopping for health insurance. Additionally, you may want to look at a preferred provider organization, or PPO, health insurance plan. PPO health plans have networks of providers, but still allow you to see any doctor out of network. Out-of-network care may be more expensive than in-network care, but buying a PPO plan is one way to keep your current doctor while buying a new health insurance plan. How do I select a Primary Care Physician? A primary care provider is a doctor who handles your routine health care. They are the person to see if you need a vaccination, have an upper respiratory infection or require help to manage a chronic health condition such as diabetes. Your primary care provider also should monitor your overall physical, mental and emotional health. When your health problem requires additional care, the primary care doctor will refer you to a specialist, such as a cardiologist or an ophthalmologist. Primary care providers also are called primary care doctors and primary care physicians. Although some people use urgent care or the emergency room for their primary care needs, that doesn't allow you to build a trusted, long-term relationship with one provider, says Dr. James Wantuck, chief medical officer and cofounder of the telehealth platform PlushCare. Wantuck is an internal medicine physician based in San Francisco. By building a relationship over time, the provider becomes a detective, like a Sherlock Holmes, to find out what's wrong when something isn't right with your health. Types of Primary Care Physicians There are several types of doctors who work as primary care physicians: A family medicine physician cares for the whole person through all stages of life, from infant to older age. They will focus on seeing you as a whole person rather than just one specific health problem, says Dr. Ada Stewart, president of the American Academy of Family Physicians and a practicing family physician in Columbia, South Carolina. An internal medicine physician specializes in care for adults. A pediatrician cares for children. An OB/GYN can be a primary care provider for some women, particularly young, healthy women. However, OB/GYNs specialize in reproductive health and aren't equipped to handle problems like strep throat, COVID-19 or other problems beyond women's health. Also, many family medicine and internal medicine physicians will handle routine gynecological care, such as Pap smears. A nurse practitioner or a physician assistant also can be a primary care provider. These providers work closely with a medical doctor, so if there's something they can't do, they'll refer to their supervising doctor, says Dr. Susan Besser, a primary care provider specializing in family medicine at Mercy Personal Physicians at Overlea in Baltimore. For instance, some states only allow medical doctors to prescribe certain types of medicines. You also may wonder about the difference between an MD (medical doctor) and a DO for primary care. Both receive similar training, but DOs (short for doctor of osteopathic medicine) also study 300 to 500 hours of osteopathic manipulation, which is a hands-on approach used to treat the musculoskeletal system. Both MDs and DOs commonly work as primary care doctors. If you have to choose a new primary care doctor because of a change in health insurance, a move or changing medical needs, for example, consider these following tips. Choosing a New Primary Care Doctor Ask friends or family. Many referrals to a primary care provider come from friends or family members. Their recommendation can be helpful because that person knows you well. However, a stamp of approval from a friend or family member doesn't always mean the doctor is a good match for you. You'll have different health issues than your friend or family member. Plus, the personality mix of the doctor and patient together is the real key to a successful relationship, says Dr. Ruth Brocato, a primary care provider specializing in family medicine at Mercy Personal Physicians at Lutherville, Maryland. If a friend or family member likes a doctor, ask what they like about that provider. This will help you determine if there's a potential match for you. Check online reviews. Online reviews are popular, but they should be a starting point, not the final say, when choosing a new primary care provider. It's always helpful if you see mostly positive reviews, as that likely indicates the doctor cares about his or her public image. No doctor wants to be the one on a review site with only one star, Wantuck says. However, negative reviews may not always be accurate, and all reviews are anecdotal. Check the doctor's background credentials. This is usually easy to find on the practice website. You can use their online information to check the following: Is the doctor licensed in your state? You can find out where a doctor is licensed to practice and their education background at the Federation of State Medical Boards website. What is the doctor's specialty: family medicine or internal medicine? Is the doctor board certified? Board certification refers to a special exam that doctors can study for and pass after completing medical school, Wantuck says. Doctors aren't required to complete board certification, but it adds an extra layer of knowledge. Board certification also requires courses that refresh the doctor's knowledge every few years. If it's important to you, you'll also want to take into account if the doctor is male or female. Ask about health insurance coverage. You can whittle down costs when you see a primary care provider who's covered by your private health insurance plan or Medicare or Medicaid. Many health insurance plans will require you to pay a small fee, or copay, for each appointment, and the plan will cover the remaining cost. Insurance plans have online tools so you can verify which local primary care providers accept your insurance. You can also call your insurance company to find providers in your area. If you find a primary care provider you like, but their office doesn't accept your insurance, talk to the provider's staff. They may be able to arrange an affordable self-pay option. The same is true if you don't have any health care coverage. If you have health insurance, your plan still may pay for a portion of the appointment as an out-of-network visit, Wantuck says. Consider the office location. How close is the office to your home? Beyond that, find out if there's parking or if the office is close to a bus or subway line. If you or a family member has special needs, ask in advance if the office has an elevator and ramps for wheelchairs and walkers, Stewart advises. Ask how long it takes to get an appointment. You can do this by calling the office and simply asking them how quickly it usually takes to get an appointment. You'll also want to ask if they have same-day appointments in case you get sick and need to be seen urgently. It also can be helpful to know how the doctor handles after-hours emergencies and non-emergencies, Stewart says. For example, is there another on-call physician, or does the office use an answering service to field nighttime calls? Another consideration nowadays: Does the office have telehealth appointments? When visiting, consider how long your wait time is. You usually can expect some waiting at any doctor's office, but you'll want to make sure you're comfortable with the average wait time. That comes with a caveat, Brocato says. "Obviously wait time is important, and I aim to be on time, but realize that I may have been delayed because I was comforting a new widow or talking to a parent whose child is struggling in school or even giving a patient a new cancer diagnosis," she explains. Evaluate how well the primary care provider listens. This is a huge factor in finding a new primary care provider, Wantuck says. Does the doctor take the time to listen to your concerns? Do you feel comfortable opening up to him or her? As part of this, find out about their philosophy of medical care to see if you agree with it, Besser advises. For instance, do they prefer to prescribe medications, or are they more interested in starting with lifestyle changes? Which do you prefer? The doctor's focus on prevention of chronic diseases, rather than only treating something once a condition develops, also can be important, Brocato says. If you have a pre-existing condition such as diabetes or high blood pressure, ask if the doctor regularly treats patients with your condition. Some patients may wish to ask if the doctor regularly treats LGBTQ patients, Stewart says. Take cues from the office environment. Staff friendliness and office cleanliness can help indicate the type of care you'll receive. When choosing a new primary care physician, you can set up a meet-and-greet visit to get a better feel for that person and the office. You'll find out more information during that visit to help with your decision, Besser says. You also can ask the doctor's office if they offer a trial period, so you can see over a few appointments if you feel comfortable going there. Even if they don't formally offer this, you should still be able to look for a new primary care provider when you want to switch to someone new. As you try to pinpoint the right primary care provider, keep in mind that it's a collaborative relationship. You don't want to contact the provider only when you're sick. Stay in touch for preventive care appointments, immunizations and when you need emotional or mental health support, Stewart says. By staying in touch, the provider gets to know you better, and that helps to build a stronger relationship. What Is an Out-of-Pocket Maximum? Definition and How It Works What Is an Out-of-Pocket Maximum? An out-of-pocket maximum is the most you have to pay per year for covered healthcare services. When you have spent this amount in your plan year on deductibles, copayments, and coinsurance for in-network care and services, your health insurer will pay for 100% of your healthcare services. An out-of-pocket maximum helps you to control the cost of your healthcare because you know the maximum you will ever have to pay in a year. The out-of-pocket maximum for marketplace plans can't be above a set amount each year. For the 2022 plan year, this amount is $8,700 for an individual and $17,400 for a family. Out-of-pocket maximums help individuals and families avoid major financial problems associated with high healthcare costs in years when they need a lot of treatment. There are some exceptions, though, so make sure you understand what is and isn't covered. Otherwise, you may end up with a nasty surprise. An out-of-pocket maximum, also referred to as an out-of-pocket limit, is the most a health insurance policyholder will pay each year for covered healthcare expenses. When this limit is reached, your health plan will cover 100% of your qualified expenses. You can generally choose from a range of plans with different out-of-pocket limits. However, plans with lower out-of-pocket maximums normally have higher premiums, and those with higher out-of-pocket maximums have lower premiums. Some individuals (or families) may qualify for lower out-of-pocket maximums if they earn under certain income thresholds or meet other requirements. Understanding Out-of-Pocket Maximums In general, an out-of-pocket maximum is the most you have to pay per year for covered healthcare services. When you have spent up to this amount on your healthcare in a year, your healthcare insurer will pay for 100% of your healthcare costs. Deductibles, copayments, and coinsurance all count toward your out-of-pocket maximum under the Affordable Care Act. In practice, however, it's a little more complicated than that. For example, there are some costs that aren't included in your out-of-pocket maximum. These include: Your insurance premiums Anything you spend for services your plan doesn't cover Out-of-network care and services Costs above the allowed amount for a service that a provider may charge These exceptions mean that even when you reach your out-of-pocket maximum for the year, you will still have to pay your premiums to stay covered. You should also be careful to use in-network healthcare providers if you want to control the costs of your healthcare, because out-of-network costs don't count toward your out-of-pocket maximum. Also, costs that aren't considered covered expenses don't count toward the out-of-pocket maximum. For example, if the insured pays $2,000 for an elective surgery that isn't covered, that amount will not count toward the maximum. This means that you could end up paying more than the out-of-pocket limit in a given year. Out-of-pocket maximum limits The highest out-of-pocket maximum you will have to pay is controlled by federal law. The government has set limits that control how much healthcare insurers can charge for covered services per year. These are: For the 2022 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,700 for an individual and $17,400 for a family. For the 2021 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,550 for an individual and $17,100 for a family Choosing an out-of-pocket maximum Different healthcare plans have different out-of-pocket maximum limits, so you may have a choice when it comes to your out-of-pocket maximum. In general, you should choose the plan with the lowest out-of-pocket maximum. This will keep the maximum amount you spend per year as low as possible. However, insurance companies balance the out-of-pocket maximums they offer against the premiums they charge. This means that plans with low out-of-pocket maximums have high premiums and vice versa. For example, Health Insurance Marketplace Bronze and Silver health plans generally have lower monthly premiums and higher out-of-pocket limits. The Gold and Platinum plans, which have higher monthly premiums, typically have lower out-of-pocket limits What is the difference between in-network and out-of-network care? What does in-network mean? In-network refers to a health care provider that has a contract with your health insurance plan to provide health care services to its plan members at a pre-negotiated rate. Because of this relationship, you pay a lower cost-sharing when you receive services from an in-network doctor. What does out-of-network mean? Out-of-network refers to a health care provider who does not have a contract with your health insurance plan. If you use an out-of-network provider, health care services could cost more since the provider doesn’t have a pre-negotiated rate with your health plan. Or, depending on your health plan, the health care services may not be covered at all. Is it more expensive to see a provider outside of my health plan’s network? Yes, typically you’ll pay more if you go to an out-of-network provider. Keep in mind that some health plans don’t have any coverage for non-emergency services received from an out-of-network provider. Be sure to check your benefits before picking a doctor or other health care provider Do I need referrals to see specialists with my health insurance plan? Whether or not you'll need a referral depends on what type of health plan you have. Typically, PPOs and EPOs do not require a referral to see a specialist. However, if you're seeing someone who is out of your network, you'll need an OK from your insurance provider first. Things You Need to Know About Getting a Medical Referral Imagine. You or your family member has a scratched eye. Maybe it’s ongoing stomach pain or a rash on your arm at random times of the year. Whatever the illness, it’s a medical ailment that goes beyond what your general doctor can handle. It’s time to call a specialist, right? Not so fast. In the United States, many health insurance companies will not allow you to just call up a specialist and make an appointment. If you want them to pay for it, you’ll need to get a referral first. What’s a referral, and how do you go about getting one? We cover the details of seeing a specialist in the US: What is a referral? Certain types of health insurance companies will not allow you to see a specialist unless you have a referral from your primary care physician (PCP). He or she will determine what kind of a specialist you need to see and recommend one (or a few) who they trust. For example, with some plans, you cannot see a dermatologist or gastroenterologist unless you see your general doctor first. This is similar to getting a prescription for medication. Your doctor’s office will help coordinate the visit with the specialist and share your health details with them. They will also communicate this to the insurance company. Before you see the specialist, double check that the referral went through. If the specialist wants to see you again, make sure that the referral covers more than one visit. How do I know if my insurance requires a referral? It depends on the type of insurance that you have. Simply said, health maintenance organization (HMO) plans and point of service (POS) plans will require a referral before seeing a specialist. On the other hand, preferred provider organization (PPO) and exclusive provider organization (EPO) plans do not require a referral. You can easily find out which type of plan you have by looking on your health insurance card. Are there any exceptions? Women do not need a referral to see an in-network obstetrician-gynecologist for routine care, such as Pap smears and mammograms. Also, visits that the insurance company considers an emergency may not need a referral. What if I don’t get a referral? There’s nothing to stop you from seeing a specialist without a referral, but the problem is that you will be responsible for the full cost of the visit. The insurance company will not cover it. So instead of paying a copay, you’ll be stuck with a much higher bill. What if I don’t have a PCP? Unfortunately, if your health insurance requires that you get a referral, there’s no way around it. Some insurance companies will assign you a PCP, so you can call that doctor to make an appointment with them. It’s always best to establish a PCP before you’re sick. Make an appointment to establish yourself as a patient at their office. That way, your doctor will have your full medical history and will be able to see you sooner (and the appointment will be faster!) when you are sick. What if I can’t wait to get a referral? If the situation is serious and you need to see a specialist immediately, you might want to consider going to an urgent care facility or the emergency room. Neither require an appointment, but you will have to wait for a doctor to have an opening to see you. How does prescription drug coverage work with health insurance? As the population ages, spending on prescription drugs has been increasing faster than other aspects of our health care costs. From 1994 to 2003, prescription drug spending rose at double-digit rates each year. And it's still rising, although the increase can now be measured in single digits [source: Kaiser Family Foundation]. A few changes in the world of prescription medication have contributed to this slight slowdown in spending -- including the way health insurance companies offer prescription drugs. Many insurance plans have excluded high-cost drugs from coverage, cut down on refills and increased co-pays. There has been much debate and research on how insurance companies can profitably meet our prescription drug needs. Let's find out what's going on. Any insurance plan's prescription drug coverage includes a formulary, or a preferred drug list. It contains the medications your plan prefers and that can usually be prescribed without any prior authorization. This list is created to keep the drug costs down for the insurance company while still offering you a competitive choice of medications. One main purpose of the formulary is to encourage you to use the generic form of a given drug. If you don't choose the generic, some plans will charge more. Others may ask for the price difference plus the normal co-pay, some have a deductible for name-brand drugs and others will simply deny the coverage altogether. A formulary can have several forms, depending on your exact insurance plan. Some plans will cover drugs that are on the formulary (preferred drugs, usually generic) and not on the formulary (nonpreferred drugs, usually brand-name), but you will generally have to pay more for nonpreferred drugs. Other insurance plans may be more cut-and-dried, covering only those drugs on the formulary and denying payment for all others without some sort of preapproval process. However, the majority of formularies fall somewhere in between these two types of plans and into a "tiered" formulary. In these plans, drugs are assigned to a tier, with each tier increasing the co-pay amount. Normally, in a three-tier plan generic drugs are found at the cheapest tier-one level. Tier two includes brand-name drugs in which generics are not available, and tier three contains drugs that aren't found in the formulary, or are nonpreferred, and thus are charged an even higher co-pay. If your doctor prescribes a drug that isn't on your health insurance plan's formulary, most plans have an authorization process in which a drug may be approved on a case-by-case basis. Usually in these situations, you must have already failed with the approved treatments or experienced adverse effects from them. If your coverage is still denied, an appeal process is usually available. So, how is a formulary created? Your insurance company has a committee that is normally composed of physicians, pharmacists and other health care providers. This committee selects drugs and other products on the formulary, keeping in mind factors like safety, efficacy and quality, along with the cost to the insurance company. Most formularies are reviewed and revised on a quarterly basis. New FDA-approved drugs may be added to the list, and noneffective or expensive older drugs may be removed. So what happens if you can't afford the co-pays, or if you can't afford health insurance altogether? Salvation may come from the oddest places. Find out where in the next section. Patient Assistance Programs Patient assistance programs can help the uninsured get the medications they need. Some of us with health insurance struggle to pay for our prescriptions, so imagine how hard it would be if you had a chronic condition and no insurance. Luckily, patient assistance programs -- funded by state governments, charitable organizations and even drug companies -- can come to the rescue. Yes, pharmaceutical companies are one of the main providers of free or discounted medication to low-income patients without insurance. Most major drug companies offer Pharmaceutical Assistance Programs (PAPs), which provide discounted or free medication to those who qualify. Some drug companies may also provide qualifying customers with a discount drug card. If you qualify for these programs, it usually means you earn too much to qualify for government-funded programs but don't make enough to afford your own health insurance. Or maybe you can't get health insurance based on your medical history and can't afford all of your medications. Each PAP has different criteria, which can be confusing for people on medications from different drug companies. So the drug industry launched the Partnership for Prescription Assistance (PPA) to help patients find the right assistance fast. The PPA provides information on more than 475 PAPs and can help patients contact Medicare or other government programs that could be of use. Several other agencies provide the same services -- Access to Benefits Coalition specializes in the aging population and Medicare information, and NeedyMeds offers information from drug companies, state and local companies and programs based on specific diseases. Saving Money on Prescription Drugs Americans spend more on pharmaceuticals per capita than residents of any other country. Here's some advice on how to save some money. Talk to your doctor: He or she could know about nonprescription options or another brand of the drug that costs less. Check into your state's drug assistance programs. Find out if you qualify for drug assistance from a PAP. Compare prescription prices online and at your neighborhood pharmacy -- prices can vary dramatically. What’s the open enrollment period, and can I get covered outside of it? The open enrollment period for health insurance is a set period of time during which individuals can enroll in or make changes to their insurance coverage. This period is generally established by the government or insurance providers, and its purpose is to ensure that individuals have a guaranteed opportunity to enroll in coverage or make changes to their existing coverage. It is also a way to balance the financial risk for the insurance providers. By having a set period during which individuals can enroll or make changes, insurance providers can better predict and plan for the number of individuals who will be covered under their plans. This helps them to better manage their costs and ensure that they have enough funds to pay for the healthcare needs of their customers. It is important to note that there are some exceptions to the open enrollment period such as special enrollment periods triggered by certain events like loss of coverage, marriage or birth of a child. To summarize, open enrollment is needed because group health insurance plans -- and all individual health insurance plans -- are now guaranteed-issue. Without the open enrollment periods, people would just wait to buy coverage until they got sick or needed an expensive medical procedure. What is a pre-existing condition, and how does it affect my coverage? A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts. Insurance companies can't refuse to cover treatment for your pre-existing condition or charge you more. How can I file a health insurance claim? In most cases, you do not have to file your own health insurance claims; your health provider usually files the claim for you after services are rendered. However, there are some circumstances under which you may need to file your claims yourself. If you have a fee-for-service indemnity plan, you may be required to file your own claim. In most cases, you do not have to file your own health insurance claims; your health provider usually files the claim for you after services are rendered. However, there are some circumstances under which you may need to file your claims yourself. If you have a fee-for-service indemnity plan, you may be required to file your own claim. If you have a Preferred Provider Organization (PPO) plan or a plan that includes a Point of Service (POS) option, you may have to file your own claims if you seek help from an out-of-network provider or at an out-of-network facility, as when traveling. If you have a short-term health insurance plan, you may need to file your own claims. If you are covered by Medicare, doctors and suppliers are required by law to file claims for you within 12 months of providing those services or supplies. However, if they fail to do so, you may need to file a claim. If it is nearing the 12-month deadline and your provider has not filed the claim, call 1-800-MEDICARE (1-800-633-4227). Ask for the exact time limit for filing a Medicare claim for the service or supply you received. If it's close to the end of the time limit and your doctor or supplier still hasn't filed the claim, ask them to direct you to information on filing the claim yourself. These are a few examples of times when you may need to file claims yourself. Read your own plan documents closely to make sure you understand all of your coverage and services, and be sure to retain paperwork about your health claims. https://www.sharecare.com/health/health-insurance/do-file-own-insurance-claims What is the process for appealing a denied claim or coverage decision? Appeals Patients and Providers can file an appeal. Internal appeals are submitted to the health insurance company directly. Call the health insurance company for instructions. External appeals must be filed within 60 days of the final adverse determination. Health plans may charge providers a $50.00 fee per appeal. It’s no secret that people and their insurance companies sometimes clash over which medical services will be covered. Here are answers to some of the most frequently asked questions about health reform and filing grievances with insurers. Q: If you feel your health insurance company is not following the new laws, who do you contact? A: If you have reason to believe your insurance company is not complying with provisions under the Accountable Care Act you can contact your state’s department of insurance to file a complaint. If you get your health insurance through your job, it’s also a good idea to discuss your concerns with your human resources department. Or you can contact the U.S. Department of Labor’s Employee Benefits Advisors for help by calling 866-444-EBSA (3272). Q: How long will the appeal process take or how soon should I expect the matter to be settled? A: You’re entitled to appeal directly to your insurer if it: denied payment for your care ruled that your care was not medically necessary said that you’re not eligible for the benefit in question claimed that your treatment is experimental claimed that you have a pre-existing condition The new law sets the following timelines for insurance companies to review and decide on an appeal: 72 hours for denials of urgent care 30 days for denials of nonurgent care you have not yet received 60 days for denials of service you have already received Q: What if my appeal with my insurance company is denied? A: If your appeal is denied, you are entitled to an explanation from your insurer. The plan is also required to explain how you can go about filing an external appeal, in which your case is reviewed by an independent third party. Keep in mind that if your case is urgent and you or a loved one are in danger of becoming increasingly ill without treatment, you can ask to have both the internal review and external review conducted at the same time. Q: Is that appeal process already available? If not, when does it take effect? A: For many people, internal and external appeals processes are already available. If your health plan went into effect on or after March 23, 2010, your insurer must comply with these laws as of Sept. 23, 2010. If you have a plan that was in place prior to March 23, 2010, however, it may qualify for grandfathered status and the new guidelines for appeals may not apply. You can learn more about grandfathered health plans and what it means for you at the web site of Families USA, a nonprofit advocacy organization. However, even if you have a grandfathered health plan, you should check with your insurer and/or state department of insurance about your right to appeal. Most states -- 44 -- already offer an external appeal process, although the laws vary greatly. All health plans are encouraged to adopt the new regulations prior to July 1, 2011. Q: If I have a grievance and I'm appealing my insurance company's decision, what do I do in the meantime? A: Ask your insurance company to continue paying for your treatment until a determination on your appeal has been made. If your request is refused, it’s a good idea to speak with the doctor or hospital treating you. Ask to arrange a payment plan or if collections can be put on hold until your appeals process is complete. Q: If I don't pay a contested medical bill, will it ding my credit? A: Yes. It’s important that you don’t ignore medical bills. Instead, work with your health care provider to arrange a payment plan so your bills are not sent to a collection agency, which providers can be quick do. That can damage your credit rating. If your bill has already been sent to collections, speak with the collections agency and ask to pay the bill right away. But don’t send a penny until you get the agency to agree to remove the bill from your credit report. What is the Affordable Care Act? Signed into law on March 23rd, 2010, The Patient Protection and Affordable Care Act (ACA) is also known as healthcare reform. Healthcare reform is not health insurance. Healthcare reform is law that makes changes to the insurance system. These changes help many more people get health coverage. They also protect consumers more than ever before. The California Department of Insurance (CDI) regulates insurance in California - including health insurance. We continue to work hard to put these reforms in place. Our goal is to protect consumers, foster the insurance marketplace so that it is vibrant and stable, and enforce the law fairly and impartially. How does health care reform affect me? If you have health insurance, you probably have already seen some of the changes in your policy. For example, most policies now let you keep your children on your insurance until age 26. Insurers cannot deny you coverage because if you have an existing health condition. And most policies now provide preventative services, such as immunizations, birth control, mammography and many other cancer screenings, with no out-of-pocket cost to you. Here are more changes: If you get sick, an insurance company cannot cancel your policy. Health insurance companies cannot turn down your application because of your health status. Women can no longer be charged more for insurance than men. In fact, insurance rates cannot be based on gender or gender identity at all. Once you buy health insurance, you do not have to pay anything for preventive care. No more annual dollar limits on coverage for essential health benefits. No more lifetime limits on essential health benefits. Insurance companies have to spend at least 80% of your premium dollars on actual medical expenses, not overhead and profit. Medi-Cal will cover more low-income individuals and families (all individuals under 138% of the federal poverty level are eligible). As part of healthcare reform, California law states that there must be a minimum set of benefits in most health insurance policies. These are called Essential Health Benefits or EHBs. Some policies sold prior to January 1, 2014 are "grandfathered" and do not have to cover Essential Health Benefits. Below is the list of the EHB categories. Essential Health Benefits include: Hospital care Visits to a primary care doctor and specialists Outpatient procedures, like surgery Laboratory tests and diagnostic services, like x-rays and mammograms Pregnancy and newborn care Preventive and routine care, like vaccinations and checkups Mental health care Emergency and urgent care Rehabilitation therapy, such as physical, occupational and speech therapy Some home health or nursing home care after a hospital stay Prescription drugs Substance abuse treatment Oral and vision care for children Affordable Care Act marketplace The Affordable Care Act (ACA) marketplace at Healthcare.gov allows you to purchase individual or family health insurance from participating insurance companies. Some states run their own health insurance exchanges, while others are part of the federal marketplace. There are no income requirements to get ACA coverage and marketplace plans are the only ones eligible for premium tax credits and subsidies. Those credits and subsidies can save you money on health insurance based on your household size and income. Affordable Care Act marketplace plans are the only health plans eligible for premium tax credits and subsidies, which help reduce the cost of health insurance. ACA marketplace plans are sold in metal tiers: Bronze, Silver, Gold, and Platinum insurance plans. These tiers are based strictly on premium and out-of-pocket costs. Here’s how the metal tiers differ: Bronze plans: Lowest premiums but highest out-of-pocket costs. Silver plans: Higher premiums than Bronze plans but lower out-of-pocket costs. Gold plans: Higher premiums than Silver plans but lower out-of-pocket costs. Platinum plans: Higher premiums than Gold plans but lower out-of-pocket costs. If you do not have coverage – Health Care Mandate Healthcare reform makes health coverage available and more affordable for millions of Americans. It gives subsidies for those who purchase private insurance and California expanded Medi-Cal to include more people and single adults. Together with the opening of Covered California's online marketplace, it is easier than ever to get health care coverage. Please see our Getting Health Coverage section for more information about your options. If someone who can afford coverage does not purchase it, they may have to pay a tax penalty. This is called the shared responsibility payment and sometimes also called the "individual mandate." Some people may qualify for an exemption, but you can find more details about this by visiting Healthcare.gov. Federal Health Insurance Plans You might consider a federal health insurance plan if you can’t get health insurance coverage through your employer. These plans are funded at least partially by the government and provide comprehensive health coverage. Protect your Business with Business Overhead Expense Business Overhead Expense insurance assures the business owner will have a business to come back to after recovering from an injury or sickness. Or have a business to sell that has not depreciated if not coming back. Some of the Benefits from Business Overhead Expense Insurance Include: Reimburse the small Business Owner - the fixed expenses of their business Including, Rent, Utilities, Insurance and Employees Salaries. Tax Advantages - Premiums for Business Overhead Expense Insurance are tax deductible to the business. Benefits can be payable after 30 days - benefits can begin after 30, 60 or 90 days. Benefit Update - assures the business owner can increase coverage as his expenses increase with no additional underwriting Residual Benefit - pays a partial benefit if the business owners can only performs some (not all) of their daily duties Key Person Replacement Key Person Replacement is an efficient way to provide successful businesses with the funds necessary to financially handle the loss of a key employee or executive due to a total long-term illness or injury that prevents them from performing their job duties. Benefits can be used at the discretion of the employer, but common uses include: Recruitment and training costs for a sound replacement Indemnify the company for lost revenue and profits Temporary staffing needs ​ Funds can be available to the business in a short as 30 days after an injury or illness of the Key Employee to help keep the business operating smoothly. Benefits can be paid monthly for up to 1 year or until the employee is recovered and back to work full-time. If the Key Employee has not returned after 12 months, a Lump Sum payment can be paid to help recover lost future revenue. Disability Buyout for Business Owners Disability Buy-Out insurance reimburses the Business or Policyholder for the purchase of a totally disabled insured’s interest in the business under a buy-sell agreement. These funds allow you and your partners to: ​ Maximize the financial return when the business is transferred, while minimizing the tax liability. Help the business survive a partner’s departure — allowing remaining owners and their families to receive the full value. Protect the disabled partners value in the business during a difficult time of recovery Benefits can be paid after 365 days of disability in either a lump sum or installments up to 5 years subject to the terms of their buy-sell agreement.

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