Journey Plan

Coverage

Benefits that work as hard as you do.

CalVEBA exists to deliver accessible, high-quality benefits at the lowest possible cost for the members we serve. We partner with leading carriers to design plans that balance access, quality, and affordability.

New Year, New Health Plan: 4 Ways to Maximize Your Benefits

The beginning of the new year is a great time to set yourself up for success with your health plan. Many people stop at plan selection and miss opportunities to make the most of their benefits, leading to gaps in care and unnecessary expenses.

Let’s walk through four key steps to help you prepare for your healthiest year yet.

Start the Year Off Right: Your Health Plan Action Steps

1. Choose Your Primary Care Provider (PCP)

Whether you changed plans or stayed with the same one, choosing (or confirming) your PCP ensures you have a trusted partner to coordinate your care and help you get the most from your benefits.

You can do this by: 

Using the provider search tool at calveba.org/Benefit-Contacts/.
Contacting The California Schools VEBA Advocacy Team at 888-276-0250 or through the online form at calveba.org/Contact.

Have the following information handy to make things easier: 

Name
Date of Birth or Social Security Number
Medical Group

Note: If you don’t select a PCP, one will be assigned to you automatically. You can change your PCP and medical group anytime during the year, but you cannot change your benefits plan until the next Open Enrollment period.

Bonus Tip: Transfer Your Medical Records

If you’re changing providers, request a medical records transfer early. This keeps your care consistent and avoids delays in treatment.

2. Schedule Your Preventative Care Appointments

Preventative care visits are important for early detection and your long-term wellness. During your visit, your doctor will recommend screenings and tests based on your age, gender, health status, and family history.

Read this blog post to learn more about preventative care and what health screenings you might be due for.

3. Review Your Benefits

Even if you’re familiar with your plan, it’s smart to revisit your Summary of Benefits and Coverage (SBC) at the start of the year. It provides a clear overview of your coverage provided by a health plan. We put together a guide defining terms, sections, and information you’ll find in there. View the guide here. Knowing your plan’s coverage and benefits will help you get the most from your benefits and save you money.

4. Ask About Continuity of Care

If you’re switching plans and have ongoing health needs, ask your new plan about continuity of care. This ensures you can continue seeing your current provider for certain conditions, including:

Acute conditions like pneumonia
Serious chronic conditions (e.g., diabetes or heart disease)
Pregnancy
Terminal illness
Care for a child under age 3
Scheduled surgeries or procedures

Each condition has a different continuity period, so contact your insurance provider early in the year to avoid disruptions in care. This helps avoid treatment delays and ensures you receive consistent care during your transition.

Bonus Tip: Confirm or Update Your Contact Information

Make sure your health plan has your current address, phone number, and email address. Accurate information helps ensure claims process smoothly, and you receive important plan updates.

Take Charge of Your Health with Personalized Support and Resources

Once your benefits are selected, make the most of the resources available to you. Whether you need guidance or practical tools, CalVEBA offers support to help you thrive.

Whole Health Coaching: Partner with a coach to create a plan that fits your unique needs, helping you improve your fitness, nutrition, and overall well-being. Get started here.
Health and Wellness Toolkits: Access practical resources that offer strategies for managing stress, improving nutrition, and staying active. Explore toolkits here.

Your Year-End Health Plan Checklist: 5 Key Actions to Take

As the year winds down, now is the perfect time to take full advantage of your health plan benefits before the new year begins. With Open Enrollment behind us, it’s easy to focus on the future, but there are key actions you can take right now to maximize the benefits you’ve already selected.

Many people miss out on opportunities to avoid gaps in care, reduce out-of-pocket costs, and make the most of their current plan. Taking action before the year ends helps you start the new year with the healthiest—and most cost-effective—plans in place.

5 Things To Do Before the End of the Year

1. Refill Your Prescriptions

Make sure you have enough of your medications to last until you can meet with your doctor, especially if you changed plans. If your medications require prior authorization, and you are changing plans, find out what the process is for the prior authorization for your new plan. Here’s how you can do that: 

You can find benefit contact information at  calveba.org/Benefit-Contacts/.
If you need help confirming if your prescription is covered by your new plan, reach out to The California Schools VEBA Advocacy Team for support at  888-276-0250. To streamline the process, have the following information ready when you call:
- Name 
- Date of Birth or Social Security Number
- Classification
- Prescription name, dosage, day supply
- Delivery method: pharmacy pick up or mail order

Important Note: Remember to review your plan’s prescription coverage documents as medication coverage can change periodically.

2. Download Your Digital ID Card

In 2025, all CalVEBA carriers transitioned to digital ID cards. Click here for instructions on how to download your digital ID card.

Pro Tip: Download or screenshot your digital IDs on your mobile device and upload them to the MyVEBA app to have all your IDs in one place.

3. Download the MyVEBA App

CalVEBA members can access their plan information online at MyVEBA. Use this portal to:

Save ID cards for yourself or your dependents
See your current health plan(s)
Review your Summary of Benefits and Coverage (SBC).

4. Update Your Contact Information

Make sure your plan has your current contact details. This helps avoid delays in claims processing, keeps you informed about your benefits, and allows you to receive important updates.

Don’t forget to include your email address. This is now a required field. Your email will only be used to send information related to your benefits, such as plan changes, coverage updates, and helpful resources.

5. Review Plan Information and Ensure Continuity of Care

Take time to review your coverage and benefits after Open Enrollment. Check details like networks, exclusions, and limitations. If you’ve changed plans, confirm that your current doctors and specialists are still in-network to avoid unexpected costs and disruptions in care.

If your provider is no longer in-network, you can contact The Advocacy Team to help you find a new provider or understand your options. You may also need to select a new primary care provider (PCP) with your new plan. Some carriers require this to coordinate care and referrals.

Understanding your coverage helps you manage costs and stay on top of your health.

Review your coverage and explore what’s new for the upcoming plan year. Log into the MyVEBA Portal to access your CalVEBA Member Benefits Guide and discover updated offerings, plan changes, and resources available to support your well-being.

Looking Ahead: Plan to Meet with Your Care Team

Before the year ends, it’s also important to take a moment to schedule any appointments you’ve been putting off. Whether it’s an annual physical, preventive screenings, or consultations with specialists, meeting with your care team ensures you’re on track to start the new year with a clear plan for your health. By addressing any health concerns now, you can avoid complications later and make the most of your current plan benefits.

We’ve put together a helpful resource to guide you in preparing for your upcoming appointments and making the most of your care team. Access the Healthy Life Hub here.

Trusting Your Gut When It Comes to Health Care

When choosing your health care team and your health plan, you want to make decisions based on reliable and sound information. This information can come from different sources like provider reviews, plan certifications, cost analysis, and more. There’s another source of insight that’s often overlooked: your own instincts. Your gut can help you evaluate your experiences and whether your needs are truly being met. When you listen to that inner voice, you’re better equipped to make the right decisions for your health.

Feel Seen & Heard: What Makes a Good Doctor-Patient Relationship?

Studies have shown that a good provider-patient relationship can lead to better outcomes, fewer errors, lower costs, and a more positive experience overall. But what does a good relationship look like?

Experts have identified five key pillars:

Respect
Engaged curiosity
Focused listening
Mutual participation
Provider self-awareness

Roundtable Discussion

These pillars can’t be objectively measured, but rather, they’re felt between a provider and patient. If you feel heard, respected, and involved in your care, that’s a sign you’re in the right hands. Watch CalVEBA’s roundtable to hear medical experts talk about the “green flags” to look for in a provider.

Save Money & Reduce Stress: Staying In-Network Matters

Once you’ve found a provider that you feel confident and comfortable with, you’ll want to pay attention to your health plan’s network. Providers can leave or join networks throughout the year. Staying in-network usually means lower out-of-pocket costs. If your preferred provider is out-of-network, that may be a sign to start comparing plan options during Open Enrollment.

Time to Check-In: How Do You Feel About Your Health Plan?

Studies show that many insured adults face challenges with their health plan carriers and those in poorer health often struggle even more. This Open Enrollment season, take a moment to reflect:

Has it been easy to get information from your health plan?
Do you feel valued as a member?
Are your needs being met?

Your Experiences Matter: Let Your Feelings Guide You

From choosing a doctor to choosing the right health plan for you, health care decisions can be stressful. They can affect your health, finances, and peace of mind. While it might feel risky to factor in your emotions, your feelings are a valid and powerful tool. As you evaluate your feelings about your health care experiences, ask yourself:

Do you like your doctor?
How did your last visit make you feel?
Did you feel listened to and respected?
Is it easy to get an appointment?
What did you like or dislike about your experiences with doctors, hospitals, pharmacies, and your health insurance carrier over the past year?
Can you refill prescriptions without hassle?
Are billing and claims questions answered clearly?
Do you feel confident in the care and coverage you’re receiving?

Take the Next Step: Turning Insight into Action

Once you’ve taken the time to reflect on your experiences and feelings, the next step is knowing where to turn for support. Whether you’re looking for a provider who truly listens or trying to navigate your health plan options, CalVEBA offers tools and resources to help you make informed, confident choices.

Five Open Enrollment Tips to Help You Find a Health Plan That Fits Your Needs

Health care isn’t one size fits all, and your health plan shouldn’t be either.

Choosing the wrong health plan can cost you more than just money—it can affect your care, your time, and your peace of mind.

Whether you’re managing chronic conditions, planning for fertility, or simply aiming to stay well, your health plan should reflect your unique needs. With so many terms and options, it’s easy to feel overwhelmed.

That’s why CalVEBA is here to help. Use these five tips to choose a plan that works for you and your family.

1. Know When and How to Enroll

Mark your Open Enrollment dates on your calendar now to avoid missing any crucial deadlines.

Missing your enrollment window could mean going without coverage or paying more than you need to.

Your employer’s Open Enrollment dates are unique. Please contact your Benefits Administrator for more information on your enrollment period to ensure you sign up for coverage within your window.

If enrolling through your employer, each organization will have a different process for where and how to enroll. Many streamline this process by making it available online. Again, this depends on your employer, but you can typically find this information through your HR representative.

2. Evaluate Your Current Health Care Needs

Since there’s no one-size-fits-all plan, it’s important to take inventory of what type of health care you need to feel your best.

This includes basic things like emergency and primary care coverage, but other services may also be important to you. When assessing your current needs ask yourself:

Do I take certain medications regularly?
Do I need access to mental health care?
Do I need comprehensive reproductive health coverage?
Do I see alternative practitioners covered by insurance like acupuncturists or chiropractors?
Do I need dental or vision coverage?

It can be helpful to review the types of care you’ve used most over the past couple of years to identify your top priorities. While health care needs can change, it’s important to be mindful of which ones tend to stay the most consistent for you.

Also, make sure the plan you choose covers the 10 essential health benefits outlined by the Affordable Care Act (ACA). These benefits include:

Ambulatory patient services (outpatient care without hospital admission)
Emergency services
Hospitalization (including surgery or overnight stays)
Pregnancy, maternity, and newborn care
Mental health and substance use disorder services
Prescription drugs
Rehabilitative and habilitative services and devices (these help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care (note: adult dental and vision coverage aren’t essential health benefits)

Be cautious of plans that seem too good to be true. While they may offer lower monthly premiums, they often don’t cover these essential benefits and may come with high out-of-pocket costs.

3. Consider Your Future Health Care Needs

Planning ahead helps you avoid unexpected costs and ensures your plan grows with you. Your health care plan shouldn’t just account for your current health care needs, it also needs to be able to cover you for future ones. Future health care needs include ones you may or may not anticipate or be planning.

These are just a few potential changes to consider when looking at health care plans:

Fertility planning
Changes in medications
Age-related screenings like colonoscopies or mammograms
Unexpected accidents or illnesses

While you can’t predict the future, choosing a plan that offers flexibility and comprehensive coverage can help you stay prepared, so you’re not caught off guard when life happens.

4. Compare Estimated Yearly Costs

When reviewing health care plans, many people focus only on monthly premiums. While this approach can work for some people who are young and relatively healthy, it can also backfire. If your health needs change or you face an emergency, a low-premium plan could lead to unexpectedly high out-of-pocket costs.

To get a clearer picture of your total health care spending, consider more than just the premium. Look at each plan’s deductibles and copays to estimate your potential annual costs.

Your total yearly costs for the year typically include:

Monthly premium x 12 months: The amount you pay each month to maintain coverage.
Deductible: How much you must spend on covered health services before your insurance company pays anything (except free preventive services).
Copayments and coinsurance: Payments you make to your health care provider each time you get care, like $20 for a doctor’s visit or 30% of hospital charges.
Out-of-pocket maximum: The most you have to spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services.
Health and drug services you’ll use: Determine the health services and prescription drugs your household usually gets. Then, estimate the services you’ll likely use in the year ahead.

Yearly costs can also work the other way around. It’s important to find out how much your employer covers and any other health care subsidies you may be eligible for that can help reduce your overall annual costs.

5. Always Review Plan Options

Even if you love your current plan, reviewing your options each year ensures you’re still getting the best value and coverage. Looking at health care plans, crunching numbers, and thinking through your health care needs can feel overwhelming. But don’t skip this step or rely solely on automatic re-enrollment. While it may be tempting to avoid reviewing your options altogether, it’s important to review your options yearly.

You might assume there’s no need to review your options if everything else has stayed the same-your income, job, household size, and health needs.

However, many changes can affect your health care plan each year, even if they don’t directly involve you. For example:

New insurers may enter the marketplace
Premiums may change based on your location
Coverage options may shift or expand

These factors can impact both the availability and cost of your plan. That’s why it’s essential to take a fresh look each year.

Open Enrollment only comes once a year—make the most of it. By following these steps and seeking the right guidance, you can find the best health care plan for you and your family.

If you find this blog helpful, check out the other blogs in our Open Enrollment series for more in-depth information here.

Your Open Enrollment Checklist

Plan Smart

Choosing a health care plan is one of the most important decisions for yourself or your family each year.

Open Enrollment is when people in the U.S. can renew, change, or cancel their health care plan and make other adjustments, like adding or removing dependents.

Although health care is essential for your well-being, navigating it can be complicated. Preparing for Open Enrollment is essential so you can choose the right health care plan for you. Let this checklist guide you as you prepare for the next Open Enrollment.

How to Get Ready

1. Review your current plan coverage

Understanding your current plan coverage allows you to evaluate how well it aligns with your health care needs. By reviewing the services, treatments, prescription medications, and costs covered under your existing plan, you can identify gaps or areas where your current coverage may be insufficient. This knowledge will help you make informed decisions when comparing plans during Open Enrollment.

Familiarizing yourself with your current plan’s provider network is crucial if you have preferred doctors, hospitals, or specialists you want to continue seeing. Check if your current health care providers are in-network or out-of-network under your current plan. This information will help you determine if you need to switch to a plan that includes your preferred providers or if you’re willing to change providers to access potential cost savings.

2. Identify any gaps in coverage

A good practice is to identify any limitations or restrictions within the plan. These rules determine how and when you can access certain health care services. By knowing the specifics of your current plan, you can see if there are any restrictions on seeing certain doctors, visiting preferred hospitals or health care facilities, or receiving specialized treatments.

This awareness will help you evaluate if your current plan matches your preferences and if switching to a different plan with fewer restrictions may be beneficial.

3. Evaluate the health care needs of you and your family

Your health care plan needs to address you and your family’s care needs. These are a few questions to ask yourself when determining your health care needs.

What sort of services do you use regularly?
Does someone in your family regularly take medications?
Are you expecting any potential health care changes in the next year?
Does anyone have a preexisting condition or congenital disease?
Do you expect your health care needs to change from last year to this year?

Everyone will have unique needs, so you need to assess what those are to choose a health care plan that fits them.

4. Consider any potential life changes

It’s difficult to know what your exact health care needs will be in the coming year, so you need to pick a plan that can help cover you in the case of unexpected events. Potential life changes can include unexpected diseases or accidents, but they also include things you plan such as pregnancy or surgery. Insurance is not just for your current medical needs; it also helps protect you so you can get the care you need when life changes occur.

Plenty of life events can also affect what plan you choose. This includes things like having a baby or adopting a child, getting married or divorced, retirement, moving to a new area, changes in income, or the loss of a spouse or dependent.

5. Build Wealth with an HRA

CalVEBA’s Journey Plan is a smart, low-cost health care option that helps you save on premiums while staying protected. It includes a Health Reimbursement Arrangement (HRA) through Gallagher’s HealthInvest HRA, which covers qualified medical expenses like deductibles, copays, prescriptions, vision, dental and retiree premiums – all tax free. You receive annual employer contributions, can invest in select funds, and use them now or save for later.* The funds roll over yearly, cover your family, and stay with you even if you change jobs or health plans.

*Plan availability is subject to employer offerings.

6. Evaluate your Medicare benefits

If you have coverage under Medicare, you should be aware of anything that may change in the coming year. There are several key factors to consider that might prompt a change in your Medicare coverage.

Whether it’s adjusting your prescription drug coverage, finding a plan with a more suitable provider network, seeking better cost-sharing options, or taking the time to evaluate your needs. Looking at these options will help you make an informed decision and select a Medicare plan that best matches your individual health care needs.

7. Look at any network changes

It’s important to review your health care plan even if you are satisfied with your current one. That’s because there can be changes to the plan or to your network of providers that may affect your care.

Changes in health care provider networks can impact your access to preferred doctors, specialists, hospitals, or health care facilities. If your current plan no longer includes your preferred providers in-network or if it restricts access to certain health care providers, it may be necessary to explore other plans that offer a broader network and greater flexibility in choosing your health care providers.

8. Consider alternative therapies and evolving care preferences

As your health care needs evolve, your priorities may shift. We see this as alternative therapies become more popular and have more research to support their effectiveness.

Consider any changes in your preferences for health care services, such as alternative therapies, preventive care, or specialized treatments. If your current plan doesn’t align with your changing priorities, exploring different plans that offer the services and benefits you value can help ensure you receive the care you desire.

9. Review dental and vision coverage

Most medical health care plans do not cover adult dental and vision benefits. Children, however, typically have dental coverage under normal health care plans.

Some people choose to pay out of pocket for dental and vision services. It’s helpful to have an insurance policy in place for dental emergencies. Those with current vision impairment or a history of dental issues will especially benefit from purchasing these plans.

10. Update your information

To ensure everything goes smoothly during Open Enrollment, ensure that all your contact and personal information is up to date. Look at these items when updating your personal information:

Your name, address, and birthday
Income level
Changes to dependents
Spousal changes
Beneficiary information

This is also a good time to organize any documents you need like tax returns or name change documents.

11. Research and compare plan options

Now that you have an idea of what your current plan offers compared to your changing health care needs, you can start researching and comparing other options.

These are some of the main things to look at when researching and comparing plans:

The cost of different plans.
The network of providers and hospitals.
Covered services.
Alternative services provided.
Plan Type (HMO, PPO, HDHP, etc.)
Plan ratings and customer service.

You’re faced with a lot of information when comparing plans, so it can help to take notes and write down any questions you may have.

12. Calculate the costs of your options

After you’ve calculated the costs of your current plan, you can use it to compare your other options. Look for plans that offer better cost-sharing or lower out-of-pocket expenses, especially if you anticipate frequent health care visits, treatments, or procedures in the coming year.

Considering your budget and expected health care expenses, you can determine if switching plans will provide you with greater financial benefits.

13. Consult with an expert

Choosing a health care plan can be confusing, you don’t have to do it alone! There are plenty of experts out there who are well-versed in the world of health care plans and the different terminology who can help guide you.

Your Benefits Administrator, human resources person or employee benefits specialist can be a great resource to help you discuss your options. You can also contact The CalVEBA Advocacy team – your dedicated health care concierge – to help answer any benefits questions you may have.

14. Be mindful of the Open Enrollment period

There are specific Open Enrollment dates each year. If you miss the Open Enrollment window, you may not be able to sign up for a plan, or you’ll be automatically renewed for your current plan. The Open Enrollment window may vary slightly depending on your employer.

Your employer’s Open Enrollment dates are unique. Please contact your Benefits Administrator for more information on your enrollment period to ensure you sign up for coverage within your window.

15. Review & Save Your Plan Documents

Congratulations! You’ve decided on a plan, signed up for it, and made your first payment. The date your plan goes into effect depends on your insurer and when you signed up.

Now that you’ve done the most difficult part of choosing a health care plan, be sure to review and save your important new plan documents so you can easily access your explanation of benefits, and have your documents ready come tax season, or if any complications arise.

If you find this blog helpful in understanding health insurance and the Open Enrollment period, be sure to check out the other blogs in this series for more in-depth information here.

Assessing a Plan’s Network in Three Steps

The quality and extent of a health plan’s provider and health care facility network can be a central factor in deciding whether to stay with a health plan or to find a new one. It’s important to have access to the care you need from providers you want while still protecting your budget.

During Open Enrollment, we recommend you assess your health plan’s network. Does it still work for you? How does it compare to other plans’ networks? Answering these questions may take a little time and research but will give you confidence in your health plan decisions.

Let’s Start with Definitions

In health insurance language, a network is a collection of providers and health care facilities who contract with a health plan to provide services to members at a rate that is less than their usual fees.

When you get care from an in-network provider or use an in-network facility, you save money. Conversely, out-of-network providers and healthcare facilities are providers and health care facilities that do not contract with your health plan. Generally, you pay more when you go out-of-network.

Common Terms

Bookmark this blog that defines common health insurance terms to help guide you as you assess and make your decisions this Open Enrollment.

Three Steps to Assessing a Network

Your comfort in seeking and receiving care is very important. Take time to make sure you’re getting the best care you can while still protecting your budget. Following the below three-step review will help you evaluate a plan’s network and if it can allow you to do just that.

1. Confirm Certifications and Quality Ratings

When it comes to entrusting your health with a provider, you can’t be too careful. Find out if your provider is a board-certified doctor at CertificationMatters.org. A doctor that’s certified by the American Board of Medical Specialties (ABMS) has:

Earned a degree from a qualified medical school.
Had 3 to 7 years of accredited residency.
A license from a state medical board.
Passed one or more exams administered by a member of the ABMS.
Continuing education requirements.

Next, look into your provider’s quality ratings. The National Committee for Quality Assurance (NCQA), for example, measures provider and health plan quality and recognizes high-quality through certain programs. Their goal is to help consumers — like you — find the best care and coverage available. You can search to see if your providers have received NCQA recognition. Do you need to see a specialist? The American Board of Medical Specialists certifies many different specialties and subspecialities that you can verify online.

2. Word of Mouth Reviews

Standardized quality measurements give you empirical data to make decisions on. However, there’s a lot to be said for other patient reviews. Getting opinions from others on a provider can give you an insight into the more intangible qualities of a physician, like bed-side manner, the office’s customer service, appointment availability, and more. Start by asking your friends, family, and coworkers for recommendations. Then, take the search online to find other patient reviews at:

HealthGrades
RateMDs.com
Vitals.com
And, for good measure, Yelp.com

3. Out-of-Network Benefits

Evaluating your plan’s network also means understanding the flexibility it offers—including how it supports care outside the network when needed. There may be times when you need to get care from an out-of-network provider or facility. To find out if someone is out-of-network, you can call their office to ask what health plans are accepted or contact The California Schools VEBA Advocacy Team at 888-276-0250 for assistance.

You can still seek care out-of-network, but you may need to be prepared for the financial impact of that choice. For most plans, if you go out-of-network, you will likely pay more. Some plan types will not cover out-of-network care at all while some cover only a portion of the costs. Look in your Summary of Benefits and Coverage (SBC) to see what your current plan covers or in the SBC of other plans to compare this benefit.

Supporting You Now and Next Year

During Open Enrollment, take the time to evaluate your plan’s network and how it has worked for you in the past year. Determining the right network coverage is a balancing act of access to top quality and controlling costs. We’re here to help if you have any questions. Call The Advocacy Team at 888-276-0250 or visit CalVEBA.org/Contact.

CalVEBA Resources

MyVEBA Portal

We’re excited to launch our new MyVEBA Portal. Get started with our new MyVEBA Portal here.

Benefit Contacts

For assistance with specific carrier benefits or issues, such as claims or coverage details, visit CalVEBA.org/Benefit-Contacts/.

Get Support

The CalVEBA Advocacy Team is here to assist with health care navigation, including appointment scheduling and quality of care. Call 888-276-0250 or visit CalVEBA.org/Contact for assistance.

Is Your Health Plan Still Right for You? 5 Key Things to Check

A lot can happen over a year. Your health, budget, life situations, and more can all change. Open Enrollment is a great time to reassess your needs and ensure your current health plan meets them. As you prepare to make your selections for coverage, use this checklist to help you see if your current health plan is working for you, your health, and your budget.

Here are five key health plan areas to check:

1. What’s Covered

Coverage, in health insurance terms, is the costs from your medical services and prescription drugs that your health plan pays. What and how much is covered under your health plan can change from year to year, and what you need covered can also change. For example, having a baby, getting married, getting divorced, and major changes in health needs, all can impact the type of health plan you need.

Your health plan gives you a Summary of Benefits and Coverage (SBC) each year. This document is an easy-to-understand overview of benefits and coverage provided by your health plan. Before you make your choices, it’s a good idea to review the SBC through the lens of your needs now rather than what you needed a year ago. If you need help finding a copy of your plan’s SBC or understanding it, we’re here to help. CalVEBA members can access their plan information online at MyVEBA.

2. How Much Are Your Costs?

Take a moment to review your total health care costs over the past year. Were there any costs that were higher than expected? Are there any trends? Consider whether you anticipate these trends to stay consistent, rise, or decrease. If you anticipate needing more care next year and expect higher expenses, it’s important to determine if your current plan effectively manages those costs. Additionally, if your financial situation changes, your current plan may become unaffordable for you.

When looking at health care costs, remember, there’s more to the total than monthly premiums. Total costs of care over the year include monthly premiums, deductibles, copayments, coinsurance, and out-of-pocket maximums. (Read this blog for definitions of these terms.) Review your expenses for each category over the past year to determine if your current plan meets your budget needs. Consider any anticipated increase in care for the upcoming year as well.

3. Is Your Care Team In-Network?

Selecting your care team — a team of health care professionals like primary care providers (PCP) and specialists that you choose to go to for care — is a personal decision. You need to feel comfortable with them as a person and confident in them as a professional.

When selecting providers and facilities, ensure they are within your health plan’s network. By choosing in-network providers and facilities, that have contracted agreements with health plans and offer services at reduced rates for plan members, you can save money.

If you’re not happy with your providers, get recommendations from friends and family and then check if they are in-network for your health plan. Your comfort in seeking and receiving care is very important. Take time to make sure you’re getting what you need from your care team while still protecting your budget with your plan’s network.

4. What’s the Customer Service Like?

During this time of year, reflect on your experience with your health plan carrier. No company, system, or process is perfect, but you deserve the totality of your experience to work for you.

Have an issue with your health plan carrier you need assistance with? Reach out to The CalVEBA Advocacy Team here or call 888-276-0250.

5. What Prescription Drugs Are Covered?

Health plans may include prescription drug coverage. You can find what’s covered and how much in your plan’s formulary or list of covered drugs. You can access this formulary on your health plan’s website, by contacting your health insurance provider directly, or reviewing the documentation provided to you when you enrolled in the plan. If you take prescription drugs or anticipate being prescribed any soon, you’ll want to review this list as coverage and costs may change year to year.

Remember, it’s important to take your medication as your doctor prescribed — at the right times and in the right amounts. Don’t stop your medication without talking to your provider. Take this time to thoroughly review your prescription drug coverage and what that means for your health and your budget. It may still work for you, or you may need to pick a different plan for next year.

New Health Plan: Here’s What to Do Next

Selecting a new health plan that is right for your health and budget is an important part of healthy living. Now that you’ve made your selection, there are things you need to do to ensure the transition to the new plan goes smoothly. These steps can prevent disruption to your care, limit out-of-pocket expenses, and help you maximize your benefits.

Revisit Your Benefits

Refreshing your understanding of what’s covered by your plan is a good idea throughout the year, especially at the start of a plan year. Your best source of information is your health plan’s Summary of Benefits and Coverage (SBC). It’s an easy-to-understand overview of benefits and coverage provided by a health plan. Health insurance companies are required to provide this document for all plan types. We know this document can be intimidating, so we put together a guide defining terms, sections, and key information. You can view the guide here. Familiarize yourself with your plan’s coverage and benefits for the most value and cost savings.

Additionally, you’ll want to check to see if there are any pre-existing condition rules. The Affordable Care Act (ACA) prevents insurers from denying coverage or charging more for pre-existing conditions. But there are exceptions. Grandfathered health plans — plans in place on or before March 23, 2010 — aren’t required to have the same ACA protections. Check to see if your new plan falls in this category and what that might mean for you.

Take Advantage of Online Resources

You don’t have to worry about bringing your plan materials on the go with you. CalVEBA members can access their plan information online through the MyVEBA Member Portal. Register and sign in to:

View Your current health plan.
Access digital ID cards for yourself or your dependents.
Review your Summary of Benefits and Coverage (SBC).
Access plan documents and benefit resources.

Transfer Medical Records

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), only you or your representative has a right to access your medical records. Providers and health plans can send your information to another provider or plan if it’s needed for care or payment — otherwise, you’ll need to permit them. If you’re changing PCPs, you’ll want to submit a Medical Records Transfer form or Medical Records Release form. Call your PCP’s office, and they can get one to you.

Choosing the Right Primary Care Provider

Health happens beyond the doctor’s office, but meeting with your Primary Care Provider (PCP) can make all the difference in managing your overall well-being. Your PCP is your go-to resource for preventive care, specialist referrals, and personalized support, ensuring your care is consistent, coordinated, and aligned with your goals.

If your plan is a Health Maintenance Organization (HMO), your PCP will also help manage referrals, ensuring you only receive medically necessary care.

Here’s how to pick your PCP:

Contact The CalVEBA Advocacy Team at 888-276-0250 or through an online form. Be sure to have the following information ready: 
- Name 
- Date of Birth or Social Security Number 
- Medical Group 
Use our new provider search tool, coming soon!

Is your new plan a Health Maintenance Organization (HMO)? HMOs typically require that you get referrals from your PCP to see specialists. That way, they can coordinate your care and make sure you’re getting what’s medically necessary.

Note: If you don’t select a PCP, one will automatically be assigned to you. You can change your PCP and medical group anytime during the year, but you cannot change your benefits plan.

Update Your Contact Information

Making sure your new plan has the right contact information for you is important. The goal is not to enable the insurance company to contact you unnecessarily. Rather, it’s to make sure that you receive plan information, claims are processed smoothly, and you get timely notifications.

Here When You Need Us

The Advocacy Team is here to help you navigate the healthcare system—whether it’s accessing care, dealing with referrals and prior authorizations, or making the most of your CalVEBA benefits for you and your family.

If you have any questions, contact The Advocacy Team at 888-276-0250 or submit a contact form. For urgent requests, use the “Urgent” box on the contact form.

Health Happens Every Day

Your wellness journey goes beyond routine doctor’s visits—good health is about daily choices to nourish and care for your body and mind. Whether you’re cooking a nutritious meal, practicing mindfulness, or getting active, every step counts toward building a balanced, healthy life.

To help you on this journey, CalVEBA offers resources designed to support your daily health efforts. Explore tips and tools for maintaining a healthy lifestyle and staying on top of your wellness goals.