You've got health coverage, but what comes next? Now that you have health coverage, you can use it to access care that may have been out of reach before. ALL IN For Health is here to help you and your family make the most of your health benefits by getting routine, preventive care so you can stay healthy. This means understanding your health benefits and the important steps you can take to get the care you need. When kids are healthy, they are better able to learn and succeed in school.
You can take four simple steps to get preventive care for your family once you have a health insurance card in hand:
- Choose a provider.
- Make appointments for annual checkups.
- Seek help when your child needs it.
- Keep your child’s health records handy.
Library of Health Coverage and Care Terms
Enroll in Health Coverage
- Eligibility: Some health plans, such as those through Medi-Cal, require you to prove that you are eligible based on how much money you make and where you live.
- Employer-Sponsored Insurance (ESI): Depending on your employer and how many hours you work per week, you may be eligible for health insurance through your job. If your employer offers health insurance, they may cover some of your health care expenses.
- Federal Poverty Level (FPL): The federal poverty level is the federal government's definition of poverty. It is an amount of money that a household makes in dollars. The government uses that level to determine whether people qualify for certain programs, including Medi-Cal and premium subsidies in Covered California. You can qualify for different health coverage options based on how your income compares to the FPL. This is always given as a dollar amount. For example, adults are eligible for Medi-Cal if they make 138 percent or less of the federal poverty level. That means that adults qualify for Medi-Cal if yearly household income is less than $33,465 for a family of four. (2016 Federal Poverty Guidelines)
- Health Insurance: A health insurance company promises to pay for specific medical services in exchange for your monthly payment.
- Health Plan: A package of medical service benefits offered to members by an insurer. Typically, each insurer offers multiple health plans to choose from.
- Individual Mandate: Under the Affordable Care Act (Obamacare), most Americans have to have health insurance—it's the law. If you don't have health insurance, you will be required to pay a tax fine (also called a tax fee or a tax penalty) for not having health insurance when you pay your taxes. You will be fined for the amount of months you didn't have health insurance, and the amount you owe increases every year that you don't have health insurance.
- Medicaid: In California, Medicaid is known as Medi-Cal. It is a partnership between the US government and the state of California in which California gets money from the US government to provide health coverage to low-income people.
- Medicare: Medicare is a program run by the US government to provide health coverage to Americans age 65 and older and some Americans with disabilities.
Paying for Coverage & Care
- Copayment: A set dollar amount that you pay when you go to a doctor or other health provider visit. The amount you pay depends on what kind of provider you are seeing, what health concern you are seeing them for, and the health plan you have.
- Cost Sharing: Where you or your family members have to pay some of the costs of the care you get. An example of cost sharing is a copayment.
- Cost Sharing Subsidies: Some people who buy health insurance through Covered California can get money from the government to help pay for cost sharing (see Cost Sharing). This is in addition to the financial help many people can get in Covered California to help pay monthly premiums (see Premium and Premium Subsidies).
- Deductible: A deductible is an amount of money you pay out of pocket on covered health care services before the insurance company begins to pay for those services. For example, if you are enrolled in a health plan with a $1,000 deductible, you must pay the first $1,000 of costs for health care services before insurance will begin to pay for your care.
- Out-of-Pocket Costs: These include health care costs, such as deductibles (See Deductibles), copayments (See Copayments), and co-insurance, that are not covered by insurance. This does not include monthly premium costs (even though those costs also come out of your pocket).
- Out-of-Pocket Max: This is the most that you have to pay for health care costs in a given year. This also does not include monthly premiums.
- Premium: The amount you pay each month for health insurance. If you have Medi-Cal, you may not have to pay a premium.
- Premium Subsidies/Tax Credits: A premium subsidy is money you can get from the US government to help pay for health coverage. If you purchase health insurance through Covered California, you can get financial help in the form of premium subsidies to help lower your monthly costs. The amount that you get is based on the amount of money you make (See FPL). The federal government pays for the subsidies. Premium subsidies are also known as tax credits.
- COBRA: If you lose your job, you can continue your health insurance plan from your employer for up to 18 months through the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
- Renewal: You must update enrollment in your health insurance every year in order to stay covered. You can choose to continue with the health coverage you have or make changes to your coverage, which can mean switching health plans.
- Benefits Package: The services, such as provider visits, hospital stays, medications, and tests, that are covered by your health insurance plan. The benefits package will also explain any cost sharing for services and limits on how much of a service you can get.
- Child Health and Disability Prevention (CHDP): This program delivers periodic health assessments and other services to children under 21 who are enrolled in Medi-Cal, or children under 19 with a family income less than or equal to 200 percent of the Federal Poverty Level. CHDP can help with medical appointment scheduling, transportation, and access to diagnostic and treatment services.
- Early and Periodic Screening, Diagnostic & Treatment (EPSDT): States are required to provide complete health care services for children under 21 who are enrolled in Medi-Cal. This includes preventive, dental, mental health, developmental, and specialty services.
- Fee-for-Service: A way of paying for health services where doctors, hospitals, dentists, and other providers are paid for each service they perform. They are paid a fee for every service they perform, which is why it is called fee-for-service.
- Managed Care: In Medi-Cal, most people are enrolled in managed care plans. The managed care plan is paid by the state to find doctors and other health care providers who will care for you and your family.
- Medical Home: A medical home is the name for a primary care doctor or other care provider who sees you for yearly physicals and routine care. That person is then responsible for helping you with all of your health care needs, including connecting you to specialists when you need them, and makes sure you get the care you need.
- Preventive Care: Preventive care is the routine care that you get when you are not sick. This can include exams and checkups. It is one of the biggest advantages of having health coverage; preventive care can help you not get sick.
- Primary Care Provider (PCP): Your primary care provider is your main doctor or other health care provider who you go to for checkups or when you get sick or have a health concern. For children, pediatricians are usually the best primary care providers.
- Specialty Care: Medical care that requires you to go to a physician specialist (such as a cardiologist for heart conditions or a dermatologist for skin conditions) rather than your primary care or family doctor.