Types of health plans in California

Most of the California’s health plans fall under 5 basic categories: traditional health insurance, Health maintenance organization, Preferred Provider Organizations, Point-of-service plans and Exclusive Provider Organizations.

Traditional insurance:

This plan is most flexible because you can choose any doctor or specialist without getting approval from primary care physician. But there are certain restrictions. Like, you have to get insurance companies approval if you are going to the hospital unless it is an emergency. In this type of plan, you have to pay a certain amount of medical bills each year before insurance company starts paying. This is called deductible. After that, you also have to pay certain percentage on each charge, called co-payment. Insurance companies will pay the rest of the charge based on what it considers reasonable. Insurance companies may limit your total expenses in any given year, called as out-of-pocket expenses. This type of plan is more expensive than other health plans and more paper work is involved to file claims.

Health Maintenance Organization:

You will have several types of HMOs in the market. An insurance company will pay expenses only if you visit a physician who is within-the-network. If you want to meet a specialist you have to get prior approval from the physician. Before entering a hospital you have to get approval From HMO. Most of the HMOs don’t want that you meet a deductible every year and pay only a small co-payment. Most of the paper work is handled by the organization.

Preferred Provider Organization:

PPOs are more flexible than HMOs when compared to traditional health insurance. You can visit any specialist or physician out of the network but co-payments will be more if you choose a physician out of-the network. Like other health plans you have to get prior approval before entering a hospital. This plan will cover checkups and other preventive medical services and most preferred providers will file your claims for you.

Point of service:

POS is similar to HMO. In this plan you can visit preferred provider and pay only a small co-payment. You can visit a physician that aren’t in the network and pay a percentage of the charge, after you’ve met your deductible, as you would with a PPO plan. There are restrictions if you visit a physician out of network. For example, prescription drugs, organ transplants, treatment for infertility and mental health services may not be included.

EPO (Exclusive Provider Organization):

An EPO is regulated by California Department of Insurance. This plan pays both physicians and other health care providers differently. EPOs covers only those expenses if you visit a physician within the network, unless it is an emergency.

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