Covered CA

Silver plans have moderate monthly costs, and when you receive care, your costs will also fall somewhere in the middle. They are a good fit for people who are moderate users of health services. While Silver plans are a great value for many people, if you’re a heavy medical user, you may consider a Gold or Platinum plan instead.

Free preventive services in all Silver plans include annual checkups, certain screenings, immunizations, prenatal care, children’s vision care and preventive and diagnostic children’s dental care.

Copays are the set amount you pay for a covered health care service. For a Silver 94 plan, a doctor visit costs $5.

Deductible is the name for the amount of money you have to pay in one year before your plan starts to pick up the costs for certain services. Many services aren’t subject to a deductible. For Silver 94, that amount for medical services is $75 for an individual and $150 for a family. There is no deductible for prescriptions or dental care.

Coinsurance is your share of costs for a covered health care service. It’s calculated as a percentage. For example, under a Silver 94 plan, you would pay 10 percent of the total cost of a wheelchair or oxygen tank after meeting your deductible, and your plan would pay for the remaining 90 percent.

Be sure the doctor or provider you want to see is participating in your health plan network. If you visit the provider before you receive your membership ID card, you may be asked to sign a statement agreeing to pay for the services if you can’t prove you have health insurance.

The provider may later send you a bill for the care. By the time you get a bill or claim from your provider, you will most likely already be entered into your health insurance company’s system. Once you have your membership ID card, simply contact your provider, provide them your membership ID card number and ask to have the bill resubmitted directly to your health insurance company.

Your plan may require you to have a primary care clinician. Your primary care clinician will help you navigate the health care system when you need assistance with specialty care, coordinating your care with other providers and helping you understand your treatment options. You can change your primary care clinician at any time.

If your new health insurance does not work with your doctor, but you are getting treatment for a serious condition, call your new health insurance company to let them know about your treatment. Depending on what illness or condition you are receiving treatment for, your new health insurance company may be able to work with your current doctor while you finish treatment. Be sure to tell your current doctor that you have new health insurance.

For questions about medications and getting your prescriptions filled, the first step is to contact your health insurance company to see if it has received your first payment and can issue you a membership ID card or a plan identification number. Ask which pharmacies you can use in order to get the pharmacy benefits of your health insurance plan.

When the information that you put on your application changes during the year, you must report it. Changes to things like your address, family size and income can affect whether you qualify for Medi-Cal or get help paying for your health insurance through Covered California.

People with Medi-Cal must report changes to their local county office within 10 days of the change. If you have health insurance through Covered California, you must report changes within 30 days.

Preventive care doctor visits are free, but if you bring up a health concern during the appointment, the visit may turn into a traditional doctor visit. That means you would have to pay a copay. The same could go for any tests that lead to more treatment or follow-up visits.

Services covered by your health insurance plan are ready to be used starting the next month after you make your first payment, even before your membership ID card has arrived.