Frequently Asked Questions and Answers
California Individual and Family Health Insurance

Can a health insurance company look at my smoking and drinking history when I apply for insurance?

Yes.  Insurance companies may look at smoking and drinking history when they decide whether to offer insurance.  The following chart summarizes underwriting information that health insurance companies have filed with the Department of Insurance.

AB 356:  Summary of Underwriting Information filed  re conditions for which no insurance coverage will be offered, application will be denied, or higher premium may be charged or benefit may be limited

 Condition  Insurance Company Action

Health problems for   which   you have not seen a doctor Automatic decline for some companies  
Health problems that a doctor can not explain

Automatic decline for some companies

Health problems for which you have not completed treatment

Automatic decline for some companies  


Automatic decline

Pregnancy, pregnancy of your spouse or significant other, planned surrogacy or adoption in process

Automatic decline

Cancer, under treatment

Automatic decline

Sleep Apnea

Automatic decline or higher premium will be charged

Severe mental disorders, such as major depression, bipolar disorder, schizophrenia or psychopathic personalities

Automatic decline

Heart disease

Automatic decline

Renal failure or Kidney Dialysis

Automatic decline

Diabetes with complications

Automatic decline


Automatic decline

Multiple Sclerosis

Automatic decline

Muscular Dystrophy

Automatic decline

Systemic Lupus Erythematous

Automatic decline

History of transplant

Automatic decline


Automatic decline or higher premium will be charged

Current infertility treatment

Automatic decline


Automatic decline


Automatic decline

Rheumatoid Arthritis

Automatic decline

Stroke, after 10 years with no reoccurring problems

Automatic decline or higher premium will be charged

Allergies, while testing is in process

Automatic decline or higher premium will be charged

Ear infections, controlled with medication

Higher premium may be charged

Lyme's disease, without symptoms after one year

Automatic decline or higher premium will be charged

Breast Implants (non-silicone)

Automatic decline or higher premium will be charged


Higher premium may be charged

Joint sprain or strain, recovered and no restrictions

Higher premium may be charged

Migraine headache, mild and infrequent with no emergency room visits

Higher premium may be charged

Mild depression

Automatic decline or higher premium may be charged


Automatic decline or higher premium may be charged

STD (Sexually Transmitted Disease)

Automatic decline or higher premium may be charged

Will a health insurance company look at my height and weight when I apply for insurance?

Yes. Insurance companies usually look at your height and weight when they decide to offer insurance. They may offer you insurance at a higher premium rate or refuse to insure you if you are overweight or obese. Some insurance companies use a measurement called the Body Mass Index (BMI) to decide. If your BMI is above 39, most insurance companies will not offer you insurance. If your BMI is 30-39, an insurance company may offer you insurance at a higher premium. If you have health problems because of your weight, such as diabetes or heart disease, an insurance company may refuse to insure you, even if your BMI is under 30.

What will cause an insurance company to offer me insurance at a higher premium rate or limit the products or benefits I can get?

Insurance companies may offer you insurance at a higher premium and/or limit the products or benefits you can purchase if you had a health problem in the past but you have recovered or you have been without symptoms for some time.  Insurance companies will also do this for minor health problems that you had in the past or may currently have.  Insurance companies argue that these conditions pose a risk that it will cost more for your health claims than if you were completely healthy.  Each application and insurance company is different.  An insurance company may charge a higher premium or limit the products offered for the health conditions below.  There may be other health conditions and time frames that are not on this list.

  • Stroke, after 10 years with no reoccurring problems;

  • Allergies, while testing is in process;

  • Ear infections, controlled with medications;

  • Lyme’s disease, without symptoms after one year;

  • Breast Implants (non-silicone);

  • Ringworm;

  • Joint sprain or strain, recovered and no restrictions;
  • Migraine headache, mild and infrequent with no emergency room visits;

  • Mild depression.

Can I change my plan later?

Downgrading is easy to do within the same kind of plan such as Share 500 to the Share 1500. Upgrading is possible if you are in good health as it is subject to underwriting.

There are a few options for payment with either carrier.
Billing - Shield monthly, quarterly Anthem Blue Cross Health Insurance bi-monthly, quarterly
Credit Card Anthem Blue Cross Health Insurance allows monthly, bi-monthly, quarterly credit card deduction
Checking account auto-deduction monthly deduction.

No. The policy can be canceled or renewed (by payment) month to month.

Anthem Blue Cross Health Insurance has an online application which tends to process very quickly. Otherwise, you can fax your completed application and copy of check (or credit card section) to 800-569-1156 to start the process immediately. You would then mail the original if paying by check. The credit card option just requires the faxed copy.

There is no fee to apply. Only the initial month's premium is submitted with the application.

The first month's premium must be submitted with the application. This can be done with a check made out to the carrier or via credit card (for Anthem Blue Cross Health Insurance of California). If the application is not approved, this initial payment will be fully refunded.

There are two different scenarios. If the applicant is in good health and there isn't much the carrier wants to check into, we usually hear back in one to two weeks. If the volume of applications is running high in underwriting, the time frame can be longer. If the carrier wants further information on something listed in the application, they will request records directly from the doctor and this can delay the processing time. It usually adds another 2-4 weeks depending on how quickly the doctor responds back to the request.

Yes. With either carrier, you have a single child or multiple siblings on one plan if they are under the age of 18.

The rates can change by class (the entire state of California or county) or when you move up to a new age band (typically at 5 year increments such as age 35-39). The stronger the carrier, the less severe and less often the rate increases. Once approved, they cannot change rates based on your medical health or claims.

This basically lets you know how the plan will treat large called catastrophic or major medical coverage. Your max-out-of-pocket let's you how much you will pay up to for covered benefits, in-network in a calendar year. Usually, the max is per person up to two people maximum. The Blue Shield Preferred Savings plans have a family deductible for 2 or more people on one plan.

A deductible is an amount that you will pay first before the plan kicks in. Keep in mind that you will still get the discounted rate (usually 30-60% off) on covered benefits, in-network even before you meet your deductible. After the deductible is met, you typically go into a % of the discounted rate. Some benefits such as maternity and brand name descriptions will have their own, separate deductible.

Most people already have a strong preference between these two models but in case you a need a quick summary, here it is.
With a PPO, you have more flexibility to choose your doctors; you are not locked into a region or a primary care doctor. You can self-refer yourself out to specialists. The trade off is that you will help share the costs when you get sick or hurt in the form of a deductible or co-insurance.
With an HMO, you choose a Primary Care Physician who has more control over referral and/or decisions regarding your care. You must remain within your medical group and within a geographic region. The trade off with this more structured approach is that there will be less out of pocket when sick or hurt. For example, for inpatient hospital, you may be looking at nothing out of pocket.
TIP HMO's have become more expensive so compare the annual premium difference with PPO options to make sure you are not paying too much.

Anthem Blue Cross Health Insurance of California and Blue Shield of California are separate, competing companies that offer comprehensive plans at the Individual and Small Group level.

Provider Networks Both companies have extensive doctor and hospital lists with 48,000 doctors and 400 hospitals up and down the state. Typically the lists overlap with doctors/hospitals participating in both. Occasionally there will be a doctor who participates with one company but not the other so it's best to check on your doctor.
Financial Strength This really is the main reason to go with the "Blues". Smaller or less efficient carriers are having difficulties with some filing for Bankruptcy. If you are with a smaller carrier that is offering significantly reduced costs, they almost definitely raise rates, lower benefits, and/or leave the market entirely. If you have developed health conditions, the other carriers will not pick you up at that time. Anthem Blue Cross Health Insurance of California is owned by Wellpoint, named the most admired health care carrier in the nation three years in a row. Blue Shield is a close second.

Currently there are a few health plans that stand out as being good values. Interestingly enough, they are also the most popular plans state-wide. All these plans combine solid carrier strength and comprehensive coverage with a high(er) deductible which helps to keep your monthly rates down. With current rate increases (last four years), this this is a smart way to insure. Check out the following plans:

SmartSense (no maturnity)
Lumenos HIA
Lumenos HSA (no maternity)
RightPlan40 (no maternity)
PPO 3500 HSA Compatible Plan
BC Life & Health PPO 3500
PPO Share 2500
HMO Saver

There are a lot of differences between a PPO and an HMO, but the biggest differences are in how you access care, and what providers you can access.

“PPO” means Preferred Provider Organization. A PPO is a healthcare network system where the providers are contracted with a carrier to provide healthcare at a discount or for a fixed fee.

Members can access care from PPO network contracted providers, or from non-contracted out-of network providers.

“HMO” means Health Maintenance Organization. An HMO is a prepaid healthcare plan that offers members a variety of comprehensive healthcare services available from a specific group of contracted hospitals and medical professionals.

If you elect PPO coverage, you can see any licensed physician or provider in the PPO-network or out-of-network. Of course, if you see a Anthem Blue Cross Health Insurance PPO-network provider, the plan’s reimbursement will be greater than if you see an out-of-network provider.

If you elect HMO coverage, your non-emergency care is managed by a Primary Care Physician (PCP); Specialty care requires a referral from your PCP. You are generally limited to seeing only providers contracted with the HMO. Most Blue Cross HMO services have no or very limited out-of-pocket cost to the member.

Depending on what your condition is and when it was diagnosed and treated, you can probably buy California health insurance. However, the insurer may do one of three things:

* provide full protection but with a higher premium, as might be the case with a chronic disease, such as diabetes;
* modify the benefits to increase the deductible;
* exclude the specific medical problem from coverage, if it is a clearly defined condition, as long as the insurer abides by state and federal laws on exclusions.

If you work for a company with 20 or more employees, your employer must offer you (through age 69) the same California health insurance coverage offered to younger employees. After you reach age 65, you may choose between Medicare and your company’s plan as your primary insurer. If you elect to remain in the company plan, it will pay first—for all benefits covered under the plan—before Medicare is billed. In most instances, it is to your advantage to accept continued employer coverage.
But be sure to enroll in Medicare Part A, which covers hospitalizations and can supplement your group coverage at no additional cost to you. You can save on Medicare premiums by not enrolling in Medicare Part B until you finally retire. Bear in mind, though, that delayed enrollment is more expensive and entails a waiting period for coverage.

No. Although you can select a California health plan such as a Anthem Blue Cross Health Insurance of California plan or buy a policy that should cover most medical, hospital, surgical, and pharmaceutical bills, no single policy covers everything. Moreover, you may want to consider additional single-purpose policies like long-term care or disability income insurance. If you are over 65, you may want a Medicare supplement policy to fill in the gaps in Medicare coverage.

What is the first thing I should know about buying California medical insurance coverage?

Your aim should be to insure yourself and your family against the most serious and financially disastrous losses that can result from an illness or accident. If you are offered health benefits at work, carefully review the plans’ literature to make sure the one you select fits your needs. If you purchase California individual coverage like Anthem Blue Cross Health Insurance of California, buy a policy that will cover major expenses and pay them to the highest maximum level. Save money on premiums, if necessary, by taking large deductibles and paying smaller costs out-of-pocket. Copyright 2011 All rights reserved