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Home > Health Insurance Basics

Health Insurance Basics

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How will you get your health insurance?

Most Californians get health insurance through their job, or they purchase an individual plan directly from an insurance company. Some Californians receive their health care coverage through a government program. Also, Californians can now buy a health plan from Covered California, a health insurance marketplace.

To make the best use of your health coverage, it is important to understand some basic terms and concepts. OPA can help you learn more about:

    • Many Californians who have health insurance belong to either an HMO or a PPO.

      What is a HMO

      • An HMO (health maintenance organization) is a kind of health plan.
      • An HMO has a network of doctors, hospitals, labs, and other providers in the plan. You must usually get your care from providers in the network.
      • You must have a main doctor, called a primary care doctor.
      • You must get a referral from your main doctor for services such as lab tests, x-rays, specialty care, and most other types of care.
      • Your HMO or your doctor’s medical group must pre-approve most services.
      • You cannot use out-of-network providers unless your HMO gives pre-approval, you have an emergency, or you are traveling and need urgent care.
      • You must live or work in the area served by your HMO. This is called the service area.

      What is a PPO

      • A PPO is a preferred provider organization.
      • A PPO has a network of doctors, hospitals, labs, and other providers. These are called the preferred providers. You usually pay less when you get your care from a preferred provider.
      • You can use out-of-network providers, but you may have to pay more.
      • You can get many services without a referral.
      • You can get many services without pre-approval.
      • You must live in your PPO’s service area.
      Health Plan Problems?

      For HMOs  888-466-2219
      For PPOs   800-927-4357

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