California Health Insurance General Info
California Health Insurance covers for expenses incurred for diagnosis
and treatment of covered medical conditions. California has many
different types of Health Insurance plans available. It is
important that you choose a plan that is right for you. If you have a
choice, it is important to choose the plan that best fits your specific
needs, budget, and lifestyle. Also, make sure that you are aware of the
state or federal agency that regulates the type of health care plan you
purchase in case you experience questions or problems. Each of the
different ways of receiving health care services has advantages and
disadvantages. It is in your best interest to become familiar with the
different types of individual Health Insurance, so you know what may be
available to you.
- Indemnity Policies- (Traditional Fee-for-Service Insurance)
- Preferred Provider Organizations (PPOs)
- Health Maintenance Organizations (HMOs or Managed Care)
Indemnity Policies-California Heal (Traditional
Fee-for-Service Insurance)
The majority of indemnity policies let you to select any doctor and
hospital that you wish when seeking health care services. The hallmark
of traditional fee-for-service insurance is choice. You are given the
choice of what provider to visit when seeking covered medical services
with few geographic limitations. When purchasing an indemnity policy,
you may often have a deductible. The deductible is the amount you must
pay before policy benefits are given. Select a Health
Insurance Plan
You can choose the amount you would like to pay for your deductible.
Once the deductible has been paid, the remaining charges are reimbursed
to you at a specified percentage determined by the policy contract. The
difference between eligible charges and the percentage paid is called a
Òco-payment,Ó and is normally your responsibility. The policy or an
employee benefit booklet (if your indemnity policy is group coverage)
will spell out the terms and conditions of what is covered and what is
not covered. Read your policy or benefit booklet before you need health
care services and ask your Health Insurance agent, insurance
company, or employer to explain anything that is unclear.
The California Department of Insurance (CDI) regulates indemnity
policies. If you have an individual or group Health Insurance
policy that is a traditional fee-for-service policy issued by a CDI
licensed Health Insurance Company, then you may contact the CDI for
assistance. Since jurisdiction is divided between state and federal
agencies, it can be confusing to determine who regulates your health
care coverage. The CDI is always available to assist consumers with
health care questions or to direct consumers to the correct agency for
assistance.
Important Points to Remember About Indemnity Policies:
- You have the freedom to choose your doctor, specialist, or
hospital with few limitations.
- Your options are seldom if ever limited by geographic
restrictions.
- You may be responsible for paying a deductible before covered
medical benefits are reimbursable.
- You may be required to pay a co-payment for covered medical
services.
- You can seek assistance from the CDI for questions regarding any
indemnity policy issued by an insurance company admitted in
California.
Preferred Provider Organizations (PPOs)
A Preferred Provider Organization (PPO) provides a list of contracted
ÒpreferredÓ providers from which to choose. You receive the highest
monetary benefit when you limit your health care services to those
providers on the list.br>
If you go to a doctor or hospital that is not on the preferred provider
list (referred to as going Òout-of-networkÓ), then the plan covers a
smaller percentage of your health care expenses or may cover none of
your health care expenses based on the contract wording of the plan.
Always check with your PPO or consult your list of preferred providers
before you seek health care services to make certain your physician or
hospital is a contracting provider (part of the network). Make sure that
your doctor refers you to health care providers within your PPO network,
if applicable.
California PPO Health Insurance may be regulated by either the CDI or
the Department of Managed Health Care (DMHC) depending on whether the
contract or policy was issued by a licensed insurance company or a
managed care company. Select
a California PPO Health Insurance Plan The California Department of
Managed Health Care regulates HMOs and plans issued by Blue Cross of
California and Blue Shield of California. The CDI regulates policies
issued by insurance companies such as BC Life and California Health
Insurance Company and Blue Shield of California Life. If you are confused about whom to call
regarding a PPO problem or concern, then consult your plan documents for
regulatory information.
Important Points to Remember About Preferred
Provider Organizations:
- You receive the highest monetary benefit when staying within the PPO
network.
- You may have the option to go outside the PPO network at a higher
monetary cost to you.
- Check to make sure your doctor or any specialist referred to you is
part of the PPO network before utilizing covered services.
- PPOs can be regulated by either the CDI or the DMHC depending on if
the company that issued the contract is a licensed insurance company, or
a managed care plan. PPOs can also be self-funded. If you need
assistance and you are not sure which agency regulates your plan you can
contact the CDI or the DMHC for clarification.
Health Maintenance Organizations (HMOs or Managed Care)
Membership in a Health Maintenance Organization (HMO) requires plan members to obtain their health care services from doctors and hospitals affiliated with the HMO. It is common practice in HMOs for the plan member to choose a primary care physician who treats and directs health care decisions and who coordinates referrals to specialties within the HMO network. The doctors and hospital personnel may be employees of the HMO or contracted providers. Since HMOs operate in restricted geographic regions, this may limit coverage for plan members if medical treatment is obtained outside the HMO network or coverage area. California HMOs are required to cover medically necessary emergency services even when outside of their coverage area. The intent of managed care products is to create less costly delivery of health care services while maintaining quality health care. HMOs offer access to a comprehensive package of covered health care services in return for a prepaid monthly amount (premium). Most HMOs charge a small co-payment depending upon the type of service provided. All HMOs in California are regulated by the Department of Managed Health Care (DMHC). If you have a complaint with an HMO, contact the member services department of your HMO. HMOs are required to have an internal complaint/grievance process in place. If you file a grievance and it has not been resolved within 30 days or there is some question as to the HMOs decision, then you may contact the DMHC for assistance. Please see contact information listed for the DMHC in the ÒResourcesÓ section of this brochure.
Important Points to Remember About Health Maintenance Organizations:
- You must obtain health care services from HMO providers, except
in certain emergency situations.
- Your choice of primary care physician is important because
he/she directs your care. Also, your primary care physician often
coordinates referrals to specialties within the HMO.
- Your options may be limited by the geographic restrictions of
the HMO network.
- You may be charged a small co-payment each time you utilize an
HMO covered service.
- You can seek assistance from the DMHC on all HMO and managed
care questions.
Content Provided by CDI CALIFORNIA DEPARTMENT OF INSURANCE
We at the Healthcare Solution hope you found this information on California Health Insurance helpful. To go back to the top and select an individual Health Plan or a California Medicare Supplement program please click on
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