Employers (between 3 and 50 employees) cannot
be refused coverage because of the medical history of one
or more employees. Some individual plans are available on
a Guaranteed Issue Basis, although premiums are higher. Limitations-
Conditions or circumstances for which benefits are
not payable or are limited. It is important to read the limitations,
exclusions and reductions clause in your policy or certificate
of insurance to determine which expenses are not covered.
Medically Necessary-California Health
Insurance
Many insurance policies will pay only for treatment
that is deemed "medically necessary " to restore
a person’s health. For instance, many policies will not cover
plastic surgery for cosmetic purposes.
Pre-Existing Conditions
Any illness or health problems you had prior to obtaining
insurance.
Group health care policies will cover pre-existing conditions
after you have been covered for up to 6 months; Individual
plans up to 12 months.
Prior Qualifying Coverage
Health plan coverage that was in effect before the
effective date of
the current or new coverage. Both individual and group plans
must credit coverage that was in effect before the start of
the current coverage toward the satisfaction of the pre-existing
conditions exclusions.
Usual Reasonable and Customary
The charges that a carrier determines normal for a
particular medical procedure in a specific geographic area.
If charges and higher than what the carrier considers normal,
the carrier will not pay the full amount charged and the balance
is your responsibility.
Questions or complaints regarding most HMOs should be addressed
to:
Department of Managed Health Care
320 West 4th Street,
Suite 750 Los Angeles,
California 90013-1105
(888) 466-2219
The Managed Risk Medical Insurance Board ( MRMIB)
1000 "G" Street,
Suite 450 Sacramento,
California 95814
(800)289-6574 or (916)324-4695
For information about the federal Employees
Retirement Security Act (ERISA) or employer
Health Insurance California 1
Health Insurance California 2
Health Insurance California 3
Health Insurance California 4
Health Insurance California 5
Health Insurance California 6
Health Insurance California 7
