HMOs, PPOs, and Other Health Plans
There are many kinds of health insurance. Each type has rules that you must follow to get care. This page tells you about common kinds of health plans.
Kinds of plans
Most Californians have an HMO, PPO, or EPO. Some Californians have a fee-for-service plan, but that is less common.
- An HMO (health maintenance organization) has a network. These are the doctors, hospitals, labs, and other providers in the plan. You must get your care from these providers.
- A PPO (preferred provider organization) also has a network. You usually have more choice of providers in a PPO.
- An EPO (exclusive provider organization) also has a network similar to an HMO. Similar to a PPO, you can usually go to a provider without a referral from your main doctor.
- Fee-for-service insurance (indemnity insurance) usually costs more than HMOs and PPOs, but it gives you the most choice of doctors. Usually, you pay part of each bill, and the doctor bills your insurance company for the rest.
High-deductible health plans
Some HMOs, PPOs, EPOs, and fee-for-service plans are high-deductible plans. High-deductible plans have lower premiums but higher deductibles, compared with typical health plans.
Group vs. individual plans
You may have an HMO, PPO, EPO, or fee-for-service plan through your job, or you may buy a plan on your own.
- If you have health coverage through a job or union, you have group coverage. Some group plans are self-insured and have special rules.
- If you buy health insurance on your own, not through a job or union, you have individual coverage.
- Under health care reform changes in 2014, individual coverage has more benefits and rights and is more like group coverage.
Many Californians have health care benefits supported or administered by a federal, state, or local government program.
Public supported health care coverage programs include:
- Medi-Cal is health insurance for people with low incomes. Most people with Medi-Cal have Managed Care plans, which are like HMOs.
- Covered California is a marketplace where Californians can choose a health plan and often are eligible to receive federal tax credits to help pay the premium. Covered California plans are primarily HMOs, PPOs, and EPOs.
- Medicare is the federal health insurance program for people who are 65 and older, and for some people under 65 who have a disability. Medicare Advantage plans are usually HMOs or PPOs. Traditional Medicare (or Original Medicare) is more like fee-for-service health insurance.
- Veterans health benefits are available to many people who served in the U.S. armed forces or were called to active duty in the Reserves or National Guard. Benefits are also available to some family members of certain eligible veterans.