Using Your Plan

Welcome, members of Covered California!

As a member, you will receive welcome information from Covered California, which will include:

You will also receive an enrollment package and membership ID card from your health insurance company.

Your health insurance through Covered California can help you cover medical costs for services such as:

  • Doctor visits.
  • Prescription drugs.
  • Emergency services.
  • Pediatric care, including dental and vision.
  • Laboratory services.
  • Maternity and newborn care.
  • Hospitalization.
  • Preventive and wellness care.
  • Rehabilitation.
  • Mental health and substance abuse services.

You may also benefit from watching this video, "Health Terms Defined."

Before You Receive Your Membership ID Card

After you make your first payment to your health insurance company, you can use services covered by your health insurance plan starting the next month, even before your membership ID card has arrived.

If you haven’t already, be sure the provider you want to see (a doctor or other health service provider) is participating in the health plan network you have selected. 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 cannot prove you have health insurance. The provider may later send you a bill (a "claim") for the care. It’s likely that by the time you get a bill or claim from your provider, you will 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.

If you have questions about whether your provider is in your plan’s network, or questions about your coverage, please call your health insurance company.

Provider Networks

It is good practice to understand a bit about the provider network you have available with your coverage. The provider network you have with your plan — typically a health maintenance organization (HMO), preferred provider organization (PPO) or exclusive provider organization (EPO) — is identified on your health plan membership ID card. Each of these network types corresponds to a list of providers offered by your health insurance company that are available to you as part of the benefits of your plan.

Verifying Your Provider Is Available

If you did not reach out to doctors to see if they take specific health plans when you were enrolling in health insurance, go to your health insurance company’s website and look up your provider (doctor, hospital, etc.). Doing this prior to making an appointment can help you with verification that your provider participates in your chosen plan's provider network.

If you see your doctor on the website as part of your plan network, but when you get to the doctor's office the doctor says he or she is not in the network, it is best to have office staff call the health insurance company while you are still at the doctor's office to verify if they are or are not accepting your health insurance.

Primary Care Provider Feature

A New Feature of PPO/EPO Plans

Beginning Jan. 1, 2017, our health insurance companies will match you with a primary care physician, who will be an advocate for you, helping you to navigate the health system when you need assistance selecting the proper specialist, coordinating your care with other providers and ensuring you understand your treatment options. While having a primary care physician is important, you can choose to navigate the health care system on your own and you do not need permission from your primary care physician to seek treatment. You will not need a referral from your primary care physician to see a specialist, either. You can change your primary care physician match at any time. Learn more on our primary care physician page.

Who to Contact

  • Contact Covered California to:

    • Report any changes to the information in your application, such as changes to your income and address. You may also add or remove dependents. These changes can affect your financial help in the form of Advanced Premium Tax Credits (APTC), so it is very important to report them within 30 days of when the change occurred.
    • Find out if you or a member of your family is eligible for Medi-Cal.
    • Get coverage through Covered California if you have Medi-Cal now but will be losing that coverage.
    • Update information such as citizenship, proof of residency and income verification.
    • Make changes to your health coverage.
    • Find out when and if you can enroll.
    • See if you are eligible to enroll during special enrollment due to a qualifying life event.
    • Cancel your coverage.
  • Contact your health insurance company to:

    • Make a payment, online or by phone.
    • Request a new membership ID card.
    • Ask a question about billing and payments.
    • Learn more about benefits and eligibility.
    • Get help finding doctors or other providers.
    • Find out how claims for services were paid.
    • Change primary care physicians.

Understanding Your Coverage Benefits

It is important to review and understand the benefits of the plan you have selected. A good way to do this is to keep a copy of your benefits summary handy as you seek services. This information can be provided by your health insurance company. This information will help determine the correct level of benefit for the care you are seeking, and in the event of continuing treatment it can help ensure the next steps for care are covered according to your plan and that you are charged correctly.

Free Preventive Care

Your health plan is not just for when you or your family members are sick. It’s also important to understand and use the preventive care that is available to you when you are well. These preventive checkups, like annual physicals and immunization vaccines, are available at no added cost to you and, more importantly, can help you stay healthy.

Most health plans offer many preventive services without charging you a copayment or coinsurance when you visit a doctor in your network. This is true even if you haven’t met your yearly deductible. Call your health plan directly to find out if the preventive services below for adults, women and children are available to you.

Preventive Care for Adults

  1. Annual adult wellness exams.
  2. Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked.
  3. Alcohol misuse screening and counseling.
  4. Aspirin use to prevent cardiovascular disease for men and women of certain ages.
  5. Blood pressure screening.
  6. Cholesterol screening.
  7. Colorectal cancer screening for adults over 50
  8. Depression screening.
  9. Diabetes (Type 2) screening for adults with high blood pressure.
  10. Diet counseling for adults at higher risk for chronic disease.
  11. HIV screening for everyone ages 15 to 65, and other ages at increased risk.
  12. Immunization vaccines for adults, including:
    • Haemophilus influenzae type b.
    • Hepatitis A.
    • Hepatitis B.
    • Herpes Zoster.
    • Human papillomavirus.
    • Influenza (flu).
    • Measles, mumps and rubella.
    • Meningococcal disease.
    • Pneumococcal disease.
    • Tetanus, diphtheria and pertussis.
    • Varicella.
  13. Obesity screening and counseling.
  14. Sexually transmitted infection prevention counseling for adults at higher risk.
  15. Syphilis screening for all adults at higher risk
  16. Tobacco use screening for all adults and cessation interventions for tobacco users.
  17. Skin cancer counseling for persons at high risk.
  18. Lung cancer screening for persons at high risk.
  19. Hepatitis C screening for persons at high risk.
  20. Falls in older adults, counseling, preventive medication and other interventions for community-dwelling adults age 65 and older who are at increased risk for falls.

Preventive Care for Women

  1. Anemia screening for pregnant women.
  2. Breast cancer genetic test counseling (BRCA) for women at higher risk.
  3. Breast cancer mammography screenings every one to two years for women over 40.
  4. Breast cancer chemoprevention counseling for women at higher risk.
  5. Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women.
  6. Cervical cancer screening.
  7. Chlamydia infection screening for younger women and other women at higher risk.
  8. Contraception.
  9. Domestic and interpersonal violence screening and counseling.
  10. Folic acid supplements for women who may become pregnant.
  11. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes.
  12. Gonorrhea screening for all women at higher risk.
  13. Hepatitis B screening for pregnant women at their first prenatal visit.
  14. HIV screening and counseling.
  15. Human papillomavirus (HPV) DNA test every three years for women with normal cytology results who are 30 or older.
  16. Osteoporosis screening for women over age 60, depending on risk factors.
  17. Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk.
  18. Sexually transmitted infections counseling.
  19. Syphilis screening for all pregnant women or other women at increased risk.
  20. Tobacco use screening and interventions, including expanded counseling for pregnant tobacco users.
  21. Urinary tract infection or other infection screening for pregnant women.
  22. Well-woman visits.

Preventive Care for Children

  1. Wellness exams.
  2. Autism screening for children at 18 and 24 months.
  3. Behavioral assessments for children up to 17 years old.
  4. Blood pressure screening for children up to 17 years old
  5. Cervical dysplasia screening for sexually active females.
  6. Depression screening.
  7. Developmental screening for children under age 3.
  8. Dyslipidemia screening for children from 1 to 17 years old at higher risk of lipid disorders.
  9. Fluoride chemoprevention supplements.
  10. Gonorrhea preventive medication for the eyes of all newborns.
  11. Hearing screening for all newborns.
  12. Height, weight and body mass index measurements for children up to 17 years old.
  13. Hematocrit or hemoglobin screening.
  14. Hemoglobinopathies or sickle cell screening for newborns.
  15. HIV screening for adolescents at higher risk.
  16. Immunization vaccines for children from birth to age 18, including:
    • Diphtheria, tetanus and pertussis.
    • Haemophilus influenzae type b.
    • Hepatitis A.
    • Hepatitis B.
    • Human papillomavirus.
    • Inactivated poliovirus.
    • Influenza (flu).
    • Measles, mumps, rubella.
    • Meningococcal disease.
    • Pneumococcal disease.
    • Rotavirus.
    • Varicella.
  17. Iron supplements for children ages 6 to 12 months at risk for anemia.
  18. Lead screening for children at risk of exposure.
  19. Medical history for all children up to 17 years old throughout development.
  20. Obesity screening and counseling.
  21. Oral health risk assessment for young children up to 10 years old.
  22. Phenylketonuria (PKU) screening for newborns.
  23. Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk.
  24. Tuberculin testing for children up to 17 years old at higher risk of tuberculosis.
  25. Vision screening.
  26. Tobacco use prevention for school-age children.

Changing Health Insurance While Getting Treatment for a Serious Condition

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 it 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 your existing treatment. Be sure to tell your current doctor that you have new health insurance.

If you would like help talking to your health insurance company, contact the Health Consumer Alliance, which offers free local assistance. Contact the Health Consumer Alliance at (888) 804-3536 or http://healthconsumer.org.

Getting Prescriptions Filled

If you have 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 premium 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. If you have not yet paid your premium bill, you will not be able to get a membership ID card.

If you need prescription medications urgently, and you have completed the Covered California enrollment application process and selected a health plan, you may be able to receive some medications. Read more on the page Prescription Drugs.

Questions and Concerns

If you have questions or concerns, contact your health insurance company.

If you are not satisfied after speaking to your health insurance company and would like to file a complaint about your health insurance company, you can call the California Department of Managed Health Care at (888) 466-2219. If your health insurance is Health Net PPO, call the California Department of Insurance instead at (800) 927-4357.

Free local assistance is available to help you if you have concerns about your health insurance company. The Health Consumer Alliance can help you work with your health insurance company, the Department of Managed Health Care and the Department of Insurance. Contact the Health Consumer Alliance at (888) 804-3536 or http://healthconsumer.org.

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