All about Health Insurance
Insurance can be confusing. Here, we will break down each type of insurance so you understand it. Our goal is to empower you to know your options, what to choose and when it is available to you.
Common Types of Insurance
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Medi-Cal
Medi-Cal is California's free or low-cost health insurance program for people with limited income, covering medical, dental, and vision care.
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Medicare
Medicare is a federal health insurance program for people 65 and older or those with certain disabilities, covering hospital care, doctor visits, and prescription drugs.
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Covered California
Covered California is the state’s health insurance marketplace where you can shop for and compare health plans, often with financial help based on your income.
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Private Insurance
Private insurance is coverage you buy, often through an employer or Covered California, covering doctor visits, hospital care, and prescriptions.
When do I enroll? During open enrollment.
Open enrollment is the annual period when you can sign up for or make changes to your health insurance plan. Enrollment periods and deadlines vary, so be sure to check the specific dates for your state or provider to ensure you get coverage when you need it.
Open Enrollment Period:
Enrollment starts - enroll, renew, or change plan. Often about a one to two month period.
During this period, you can continue to edit, enroll, renew your selections up until the deadline.
Deadline to enroll for coverage for the year. Changes, edits, or enrollments cannot be made.
Special Enrollment Periods (SEP) for enrollment outside of the annual open enrollment period:
January 16
Qualify for SEP due to a life event or income change, like marriage, pregnancy, moving, or job change.
October 31st
Need more help determining your insurance options?
Answer a few questions and let us guide you down the right path.
Medi-Cal
Medi-Cal is California’s free or low-cost health insurance program. It helps people under certain income levels get medical care. Medi-Cal covers doctor visits, hospital stays, and more.
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You may qualify if:
You are considered low-income. For example, for a family of 5 the income limit is $50,481 or below. The amounts change every year.
You are pregnant.
You are age 65 or older.
You have a disability.
You are under 21 years old.
You are enrolled in programs like CalFresh (Food Stamps, EBT), SSI/SSP, CalWorks (AFDC), Refugee Assistance, Foster Care or Adoption Assistance Program.
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Medi-Cal covers medically necessary care such as:
Doctor visits and hospital care
Prescription medicines
Dental and vision services
Mental health services
Preventive care like check-ups and vaccines
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Medi-Cal makes it easier to get health care when you need it. Whether it’s a regular check-up or something more serious, you are covered. You don’t have to worry about paying large medical bills. You can focus on your health and well-being.
If you qualify for Medi-Cal, you may not have to pay for your health insurance or services. That means doctor visits, medicines, and even hospital stays may be covered at no cost to you.
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There are several ways to get started on your Medi-Cal application:
Online: Visit the Medi-Cal website and fill out an application.
By Phone: Call your local Medi-Cal office to apply over the phone.
In Person: Visit your local county office to get help with the application.
Enrollment Assistance with AltaMed: Give us a call at (877) 462 - 2582, or explore our enrollment resources for more information. At AltaMed, we are more than happy to help.
Medicare
Medicare is a federal health insurance program for people age 65 and older, or for younger individuals with certain disabilities. It helps cover medical costs like hospital stays, doctor visits, and prescription drugs.
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You may qualify for Medicare if you are:
Age 65 or older: Most people qualify for Medicare once they turn 65.
Under 65 with certain disabilities: If you've been receiving Social Security Disability benefits for at least 24 months, you may qualify.
End-Stage Renal Disease (ESRD): Individuals with permanent kidney failure who need dialysis or a transplant may also qualify.
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Unlike Medi-Cal, which provides health care in an all-inclusive package, Medicare is broken down into four "parts". It is important to understand each part and its associated costs.
Part A (hospital insurance) typically has no premium if you or your spouse worked and paid Medicare taxes. There’s a deductible for each benefit period (usually every time you’re admitted to the hospital) rather than an annual deductible. In 2025, this Part A deductible is $1,676 per benefit period.
Part B (medical insurance) covers doctor visits and outpatient care. You’ll pay a monthly premium. This plan has an annual deductible of $257 in 2025. Once you meet this deductible, Medicare typically covers 80% of the costs for approved services, and you pay the remaining 20%.
Part D (prescription drug coverage) helps with medication costs. It may be added to Original Medicare. It is optional and requires an additional premium. You may also Part D by joining a Medicare Advantage Plan. Part D plans may have an annual deductible, however, some plans have no deductible for certain medications.
Supplemental Insurance: You can buy a Medicare Supplement Plan (Medigap) or a Medicare Advantage Plan (also known as Part C) to cover additional costs like co-pays and deductibles. Part C or Medicare Advantage plans encompass Parts A and B and often include prescription drug coverage (Part D). They may also offer extra benefits like vision, hearing and dental.
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Medi-Cal makes it easier to get healthcare when you need it. Whether it’s a regular check-up or something more serious, you don’t have to worry about paying large medical bills. You can focus on your health and well-being.
If you qualify for Medi-Cal, you may not have to pay for your health insurance or services. This means provider visits, medicines, and even hospital stays could be covered at no cost to you.
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Automatic enrollment: For Medicare, if you're already receiving Social Security benefits, you'll be automatically enrolled in Part A when you turn 65.
Manual enrollment: If you're not receiving Social Security, you'll need to apply for Medicare. You can do this online at the Social Security website or by visiting a local Social Security office.
Covered California
Covered California is the state’s health insurance marketplace where you can shop for and compare health plans, often with financial help based on your income, and often when you don’t qualify for state programs.
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You may qualify for Covered California if any of the following is applicable to you:
California residents who are U.S. citizens, nationals, or lawfully present immigrants.
People without access to affordable health insurance through their employer or Medi-Cal.
Financial help is available based on income and household size.
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Open Enrollment: This happens once a year, Nov 1 - Jan 31, and is the main time you can apply or make changes to your health insurance plan.
Special Enrollment Period (SEP): If you miss open enrollment, you can still apply if you have a qualifying life event, such as:
Losing other health coverage.
Moving to a new area with different plan options.
Getting married, divorced, or having a baby.
Changes in income affecting your eligibility.
If you think you qualify for SEP, you’ll need to apply within 60 days of your life event. Don’t wait—your window to apply is limited!
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Check Your Eligibility: Use the Covered California website to see if you qualify for financial assistance.
Create an Account: Sign up online or call their service center for help.
Compare Plans: Review options like HMO and PPO plans, comparing costs and coverage. For more information, see answer to the question below.
Enroll: Choose your plan (HMO or PPO) and submit the required documents to finalize enrollment.
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It can get confusing, but simply put:
HMO (Health Maintenance Organization): Requires you to choose a primary care doctor and get referrals to see specialists. Care is limited to a specific network of providers, but costs are usually lower.
PPO (Preferred Provider Organization): Offers more flexibility to see doctors and specialists without referrals, even outside of your network, but you will be responsible for paying a portion of the cost (usually around 20%). Think of it as being able to select your preferences.
How to Choose:
If you prefer lower costs and don’t mind sticking to a network, an HMO might be better.
If you want more freedom to choose doctors and specialists or need out-of-network options, a PPO might be a better fit.
Covered California lets you compare both types of plans side by side to decide what works best for your needs, check it out here.
Don’t forget, our team of certified and licenses enrollment specialist can walk you through this and help you choose.
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The cost depends on the health plan you choose (HMO or PPO) and your household income. Key expenses include:
Premiums: Monthly payments to keep your coverage active. Financial help, like subsidies or tax credits, can reduce these costs based on your income.
Deductibles: The amount you pay for covered services before your insurance starts paying.
Copays and Coinsurance: Small fees for doctor visits, prescriptions, or other services.
Good to Know:
Many qualify for subsidies, which can significantly lower premiums.
Some plans have low or no costs for low-income households.
Private Insurance
Private insurance is health coverage that you buy from a company, either on your own or through your employer. It helps pay for medical costs like doctor visits, hospital stays, and prescriptions, with different plans offering various levels of coverage and costs.
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Through your job: If your employer offers health insurance, you can enroll during your company's Open Enrollment period. This is often managed by your company's Human Resources (HR) department.
On your own: You can buy a plan directly from an insurance provider or (more commonly) through Covered California, the state's health insurance marketplace. Covered California lets you compare plans from different companies and offers financial help if you qualify, based on your income. Open Enrollment is usually in the fall, but you may also qualify for a Special Enrollment Period (SEP) if you experience a major life event, like losing your job or moving.
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Yes, there are a few! You have probably heard of terms like HMO and PPO. These are all different types of plans that you may choose when purchasing private insurance.
An HMO (Health Maintenance Organization) plan provides a list of approved providers—such as doctors, hospitals, and more—that you can visit. This list, known as your network, depends on your location.
In simple terms, you start by seeing a primary doctor, who will refer you to a specialist if needed. When this happens, they’ll “request authorization” and your medical group can approve the request. This is all to make sure that you are in network and covered through your insurance plan.
You can opt for a health maintenance organization plan if you do more routine work like yearly checkups and don’t often need specialists. HMOs are often more economical.
A PPO (Preferred Provider Organization) is ideal for people who want to see specialists without needing approval from a primary doctor. While you still have a network of doctors to choose from, it offers more flexibility in how you seek care. You can also visit providers 'out of network,' but you may have to pay higher costs.
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The cost of private insurance depends on the plan you choose, your age, family size and other factors. When deciding which plan to choose, don't forget to consider the following:
Premiums: This is the amount you pay every month for insurance. Think of it like a gym membership— you pay the monthly fee regardless of whether you go or how much you use the facilities.
Out-of-Pocket Costs: These are expenses not covered by your premium—they come directly from your pocket. There are a few different types of costs in this category:
Deductible: This is the amount you must pay out of pocket before your insurance begins covering costs. For example, if your plan has a $1,000 deductible, you’ll need to pay that amount within the year before your insurance starts covering the rest.
Out-of-pocket maximum: Just like there is a deductible (the minimum you must pay to be covered), there is also an out-of-pocket maximum. Once you reach your out-of-pocket maximum, your insurance covers 100% of your out-of-pocket costs for the rest of the year.
Copay: This is a set fee you pay each time you visit a doctor or specialist. For example, if you visit your doctor, you may pay a $20 copay, and the insurance will cover the rest. Copays are fixed fees for services like doctor visits or prescriptions, separate from the deductible, with insurance covering the rest.
Coinsurance: After you meet your deductible, some services may require that you pay a percentage. For example, with a 20% coinsurance, you’d pay $20 of a $100 bill, and insurance pays the other 80%.
Let’s put it all together now.
Health insurance, health care providers, and other parties work together to make health care accessible and affordable. Here’s how it works:
Health Insurance: Your insurance plan helps cover a portion of your medical costs. You pay a monthly premium to keep your coverage active, and the insurance helps share the costs when you need care.
Health Care Providers: Doctors, hospitals, and clinics provide medical services. They work with your insurance to bill for treatments, tests, and procedures. This means you usually pay only a portion of the total cost, such as a copay or coinsurance.
Pharmacies and Specialists: If you need medications or specialty care, your insurance often covers a percentage of these costs too. It’s based on your plan’s benefits.
