Most Californians have a health plan such as an HMO or PPO that they get through their employer or buy on their own. Most Medi-Cal members also have a managed care plan such as an HMO. Fee-for-service coverage is less common.
Some HMOs, PPOs, EPOs and other plans are
high-deductible plans. High-deductible plans have lower premiums but higher deductibles, compared to typical health plans. Higher deductibles usually mean that you pay more out of pocket for health care services before your health plan starts paying its share.
What is an 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.
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What is a PPO?
- A PPO (preferred provider organization) is a kind of health plan.
- 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 from your main doctor.
- You can get many services without pre-approval from your PPO.
- Certain services may require a referral or pre-approval.
- You must live in your PPO's service area.
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Other Kinds of Plans
EPO (exclusive provider organization) is a kind of managed care plan like an HMO or PPO. An EPO has a network of doctors and other providers that you have to use to get care (similar to an HMO). Similar to a PPO, you can usually go to a provider without a referral from your main doctor.
Point of Service plan is a type of managed care plan that combines the characteristics and rules of an HMO and PPO.
Fee-for-service insurance (indemnity insurance) usually costs more than HMOs and PPOs, but it gives you greater choice of doctors. Usually, you pay part of each bill, and the doctor bills your insurance company for the rest.