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Types of Health Coverage​

There are many kinds of health coverage. Each type of insurance plan or coverage program has rules that you must follow to get care. Many people buy an insurance plan on their own or through their employer. Other people get health care through public programs. This tells you about common kinds of health coverage.

Public Programs

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 peoples with Medi-Cal have Managed Care plans, which are like HMOs. You can apply for Medi-Cal through the BenefitsCal website.
  • 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 and 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.

In addition to the full-coverage programs listed here, there are also some programs that provide coverage for specific health conditions or needs. See Limited-Scope Public Programs.

Kinds of Insurance 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 of health care providers. These are the doctors, hospitals, labs, and other providers in the plan. You must get your care from these providers. Learn about HMO costs.
  • A PPO (preferred provider organization) also has a network. You usually have a greater choice of providers in a PPO. Learn more about PPO costs.
  • 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 greater 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 to 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 similare to group coverage in many respects.

 

 

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.