Health Insurance

Health Insurance

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health insurance plan will usually cover one person, or a family, on one plan. While an individual or family health insurance policy may cost more than a group policy it is better than not having health insurance coverage at all.

Most insurance companies offer the same types of managed healthcare plans to individuals that are offered to groups: HMO’s (Healthcare Maintenance Organizations), PPO’s (Preferred Provider Organizations) and POS’s (Point of Service Plan), and generally offer different levels of deductible to keep premiums within the consumer’s budget. Each person or family must determine what coverage, premium, deductible and out of pocket expense will best suit their needs and their family budget. Unlike group insurance that is available to an entire assemblage of people, no matter what their health status, almost all insurance companies require extensive questioning about medical history and sometimes a physical exam in order to qualify for individual insurance.

We are here to assist you in finding a plan that protects your family while staying within your budget. Please contact us today to help evaluate your health insurance options.


  • Group/Individual/Family
  • Disability
  • Supplemental/Medicare
  • Certified Agents for ACA Affordable Care
  • Dental & Vision
  • Medical
  • Short Term Insurance
  • Supplement Health Coverages
  • International Health Coverage (Individual & Group)

That’s why it’s so important to keep up with health care reform’s changes. on this site, we explain the changes – and tell you what impacts youInternational Health Coverage




Q. What is a deductible?
A. A deductible is the amount you pay each calendar year before health insurance benefits are paid for covered medical expenses.

Q. When does my deductible start over?
A. Your deductible starts over each year on January 1st.

Q. What is coinsurance?
A. Coinsurance is the percentage of covered expense you are responsible for after you meet your deductible. For example, you can choose 20% coinsurance of $5,000 (which equals $1,000). That means you’ll pay 20% and we pay 80% of the first $5,000 (which equals $4,000) of covered expenses. After that, we pay 100% of covered charges for the remainder of the year, up to the policy maximum.

Q. What is a co-payment?
A. A co-payment is a set amount that you pay for a specific service, such as $25 for an office visit. You are usually responsible for payment at the time of service.

Q. What is individual out-of-pocket expense?
A. It’s the maximum amount in covered charges you’ll pay-per person, per calendar year. The amount is determined by adding you deductible and coinsurance together. For instance, if you have a $1,000 deductible and 20% coinsurance of the next $5,000, the most you’ll pay is $2,000.

Q. What is family out-of-pocket expense?
A. Like individual out-of-pocket expense described above, it’s the combined total of your deductible and coinsurance, but for your whole family – which is the maximum amount in covered charges you’ll pay no matter how many members of your family collect insurance benefits.

Q. What is the difference between a network and non-network (or out-of-network) medical provider?
A. A network provider is a doctor or hospital who’s made and arrangement with us to provide services at a discounted rate. Non-network provides haven’t arranged to provide services at a discounted rate for our customers. Simply put, you’ll typically pay less for services from a network provider than a non-network provider.

Q. What is a Preferred Provider Organization (PPO)?
A. A PPO is a large group of doctors and hospitals who’ve agreed to provide their services to our customers at a discounted rate. Buy a PPO plan to reduce your premium and out-of-pocket costs.

Q. What is an indemnity plan?
A. An indemnity pan, also called a traditional health insurance plan, gives you the freedom to choose any doctor or hospital for your care. And since an indemnity plan isn’t associated with any network, you won’t pay any penalty for choosing a particular doctor or hospital. Premiums for an indemnity plan are higher than PPO plans. Plan Differences


Q. Different plans have different benefit maximums. What does that mean?
A. The lifetime benefit maximum is the total amount a plan will pay out for as long as you own it. While it’s rare for claims to exceed a $2 million maximum, it does happen. And if it happens to you, it’s almost certain to bring serious financial hardship. You’ll be glad to know we offer one of the nations highest lifetime maximums – up to $5 million.

Q. Some plans require referrals. What should I look for?
A. It is true many plans, like HMO’s, require a referral before you can see a specialist. It’s a way to control costs, but it can become burdensome.

Q. Do all health plans offer the same benefits?
A. Not all health plans offer the same benefits. When you’re shopping for health insurance, look for plans that offer a renage of options. Within your budget, look for plans that cover the essentials and meet your individual needs. The amount of benefits provided depends upon the plan selected and the premium will vary with the amount of benefits.

Q. Do plans cover dental care, eyeglasses, contact lenses, or hearing aids?
A. Generally, health insurance plans for individuals and families do not cover dental care (unless it’s caused by an accident), eyeglasses, contact lenses or hearing aids.


Q. How can I help reduce the costs of my insurance coverage?
A. The easiest way to reduce your costs it to buy a plan with a higher deductible. Wit a higher deductible, you share more of the cost of your care. But, if you don’t have a need for care, the good news is you’re not spending money for benefits you won’t use.
In addition to choosing the right plan design, a Health Savings Account (HAS) is a terrific way to offset costs. This special type of account offers tax term care plans.


Q. Sometimes I need prescription drugs. What kind of coverage is important?
A. Prescription drugs are expensive. And costs seem to be going up every day. Look for a plan that doesn’t limit prescriptions.

Q. What prescription drug coverage options are available?
A. Your options will vary by state and the plan you choose, but you’ll typically have a choice of deductibles and co-payments. For instance:

  • $0, $250 or $5000 deductibles
  • $10 copay on generic prescriptions
  • $25 copay on brand prescriptions, plus 20% coinsurance

Q. How do I use my prescription drug card?
A. Each time you fill a prescription. Present your card at a participating pharmacy. You’ll find information on participating pharmacies on the back of your card. If you have a plan with a prescription copay, once you satisfy your annual deductible, you’ll pay the co-payment specified on your drug card. After applying any discounts, deductibles, or co-payments, the pharmacy will submit your claim electronically.

Q. If my doctor prescribes a brand-name drug for me, will it be covered?
A. In most cases a brand-name drug will be covered. However, if a comparable generic drug is available; our plans are designed to encourage generics. If you choose the brand-name drug when a generic is available and additional charge may be applied.


Q. Which plans include child preventative care?
A. Most plans cover baby and child wellness exams, as well as immunizations.

Q. How long can my dependent children remain on my policy?
A. The age at which dependant children cease to be covered varies, depending on the kind of plan you have, the state where your policy was issued and where you live. Disabled children may remain on a policy indefinitely.


Q. What should I consider when looking at a health plan and the company that offers it?

  • It’s about more than just the premium. When comparing health plans, assess the standard benefits that each company has to offer.
  • Think about if there are limits on important things, like prescription drugs and hospitalization.
  • Look at the available lifetime benefit maximum and how the company pays for ambulance service, which can be very expensive. Beyond what a plan offers, you’ll want to look at a company’s experience and focus – since it takes a long time to become an expert at health insurance.
  • You’ll also want to look at the company’s strength and stability, so you can be rest assured that a company is financially stable and will be there when you need it.

Q. What is the difference in plans with higher or lower premiums?
A. It’s really about choice and trade-offs.
Typically, you’d chose a higher premium plan if you want your health insurance plan to pay mainly for routine needs, like a doctor visit or a prescription. It feels affordable to pay only $25 copay at the time of visit, but you’ll pay more for the convenience of knowing what you’ll spend every time you visit the doctor or need a prescription.
You’d choose a lower premium plan if you want your health insurance to protect you against a serious illness or injury. You’ll pay more out of your pocket for the costs associated with everyday health care needs – but you’ll pay less overall in premium.


Q. What is a Health Savings Account (HSA)?

  • A Health Savings Account (HAS) is an account that works like an individual Retirement Account (IRA), except the money saved is earmarked for future health care costs.
  • Anyone who buys a qualified high deductible health plan (one that meets the requirements the government has determined), with at least a $1,000 single or $2,000 family deductible, qualifies for an HAS.
  • The money you deposit into your Health Savings Account, as well as the earnings, is tax-deferred. You can withdraw money at any time to pay for qualified medical expenses, with out being penalized.
  • You can even roll over unused balances form year to year.
  • Gain greater control over you health care dollars. You can withdraw your funds for qualified medical expenses as you need them. Your withdraws are tax-free and penalty-free when you use them for qualified medical expenses.


Q. What is California Medicare?
A. California Medicare is a health insurance program generally intended for citizens or permanent residents of the United States. If you are new to Medicare, it is important to know that you’re entitled for Medicare benefits when you turn 65 years or older if you are a United States citizen or a permanent legal resident for five years or more.

However, if you are younger than 65 years old and new to the Medicare program, you may qualify for Medicare if you have certain disabilities, permanent kidney failure, or amyotrophic lateral sclerosis (Lou Gehrig’s disease).


If you are new to Medicare, there are four parts of the Medicare program you should be familiar with:

  1. Hospital Insurance (Part A) – Medicare Part A pays for inpatient hospital care, critical access hospitals (small facilities that provide limited services for outpatient and inpatient in rural areas), skilled nursing facilities (following a hospital stay), hospice care, and some home health care. It is important for those new to Medicare to know you may be automatically enrolled when you turn 65. Part A is free for most people, even if you are new to Medicare, as long as you have paid Medicare taxes while working at least ten years in a Medicare covered employment. Part A does have deductibles for hospitals stays and stays at skilled nursing facilities.
  2. Medical Insurance (Part B) – For those new to Medicare, Medicare Part B pays for doctor’s services and other medical services and supplies that are not covered by hospital insurance. Medicare pays for 80% of the “reasonable charge” for Part B covered services after you have met your yearly deductible and you pay for the remaining 20%. Those new to Medicare should be aware Part B has a monthly premium that depends upon your income. For people who are new to Medicare, enrolling in Part B is a choice. You can sign up for Part B anytime during a seven-month period that starts three months before you reach age 65. However, keep in mind that you may incur a penalty if you do not buy Part B when you are first eligible.
  3. Medicare Advantage (Part C) – Medicare Part C is another health plan choice that must provide as much coverage as your Part A and Part B coverage and sometimes offers additional coverage (like dental or vision). Those new to Medicare will want to be aware that some Medicare Advantage plans include Part D, prescription drug, benefits as well. Part C plans are normally provided through one of these options: an HMO, a PPO, or a PFFS. If you are new to Medicare, look for a comprehensive plan finder to compare Medicare plans.
  4. Prescription Drug Coverage (Part D) – Those new to Medicare may not know Medicare Part D is associated with your prescription drug coverage. Part D plans have a monthly premium and a list of covered drugs, a “formulary”, which determines if your medications are covered by the plan and at what cost. There are a variety of Part D plans available and many vary in terms of formulary and costs – whether you are new to Medicare Part D or switching plans. Those new to Medicare should know that Part D coverage can be available as a stand-alone plan or can be bundled in a Medicare Advantage Prescription Drug plan.


If you are new to Medicare you should know Medicaid is different from Medicare and provides services for people who have low income or limited resources. Medicaid is operated by each state and if you are new to Medicare and want to learn more about Medicaid you can visit


That’s why it’s so important to keep up with health care reform’s changes. on this site, we explain the changes – and tell you what impacts you.


By answering just a few questions, you can find out what the law means for you and how you may be affected. Learn More


When does it all take effect? See what’s happening with an interactive timeline of health care reform changes. Just scroll and click, and you’ll soon become an expert. Learn More


Reform can be complicated. What do all the changes mean? We break down each reform law for you in everyday terms. Dig deeper and get a clear understanding of the new laws. Learn more

Health Insurance Marketplace

Health insurers must spend premium dollars mainly on health care claims and improving the quality of care, rather than on administration and overhead costs. If they don’t, they must pay a rebate to members. READ MORE

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Windfall Insurance Services Inc
2335 Roll Dr #6

San Diego, CA 92154

(619) 661-0505
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(866) 610-0616