California Insurance Regulations

In the interests of protecting its citizens and ensuring fair, affordable coverage, California has developed a number of insurance rules and regulations. These standards provide protection for individuals and families seeking coverage, and mandate levels of guaranteed issue, rate restrictions and pre-existing condition exclusion.

Typically, individual health coverage is necessary when your employer or organization does not offer group or health benefits, or if you cannot be assigned as a dependent on another person’s policy.  Many people who elect these policies are self-employed, or contractors or have a group policy available from an employer. 

For detailed information on the unique requirements and specifications of small business coverage, please refer to our Small Business Coverage page.

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What are statewide rules and protections for individual insurance?   

CA Health Insurance - Guaranteed Issue:

• All products do not have guaranteed issue.
• Some products do have guaranteed issue- and it’s continuous for some individuals.  They are guaranteed the benefit of buying a standard health policy from any individual market insurer- regardless of health status.  It is comparable to the insurance offered in the High Risk Pool.
• A person qualifies if:
• If the individual has 36 months of prior continuous coverage through the High Risk Pool.
• If the individual has been enrolled in the standard benefit plan, but moved outside of coverage.  Must apply within 63 days of coverage and meet certain requirements.

CA Health Insurance - Rate Restrictions:

• There is no community rating.
• There are no limits on rating.
• There is not a health status rate band.
• There are exceptions: If you qualify for guaranteed issue, the premium rates for the standard policy are restricted at 110% of the standard rate.

CA Health Insurance -Pre-Existing Condition Exclusion Rules:

• Elimination riders are not allowed.
• The maximum look-back period is 12 months, if there are 3 or fewer people on the policy.  If there are more than 3 people on the policy, then the maximum period is 6 months.
• The maximum exclusion period is 12 months, if there are 3 or fewer people on the policy.  If there are more than 3 people on the policy, then the maximum period is 6 months.
• Credit is given if you have had previous coverage.

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