Not all health plans are the same. There are options depending upon your needs and qualifications.
An HMO is a health maintenance organization.
The Department of Managed Health Care (DMHC) oversees all HMOs in California and some other kinds of health plans.
- An HMO is a kind of health insurance that has a list of providers, such as doctors, medical groups, hospitals, and labs. You must get all of your health care from the providers on this list. This list is called a network.
- Usually you have a main doctor, who is part of a medical group that has a contract with the HMO. Your main doctor is your primary care doctor and manages your care. If you need to see specialists, get tests, or be in the hospital, your doctor will request authorization and the medical group must approve the service.
- Usually you pay a fee, called a co-pay, for each service.
- You may also have a yearly deductible. This is the amount you must pay each year before your HMO pays for any services.
- An HMO has a service area. You must live or work in one of the zip codes in the service area to join the HMO.
The HMO Report Card can help you compare the quality of care for HMOs and medical groups in California.
DMHC also oversees some dental and vision care plans, behavioral or mental health plans, and chiropractic plans. These are called specialized plans and cover only certain kinds of care. HMOs often use these plans to give specialized care to their members.
Review these additional resources for Information on Healthcare Quality.
PPO, POS & EPO
A PPO is a preferred provider organization. A PPO is good plan for people who want to see providers without prior approval from their health plan or medical group and who do not want to choose a primary care doctor.
You get most of your health care from a network of doctors and other providers. You can choose to go outside of the network for some care and pay a higher cost. You usually pay a yearly deductible before the PPO starts to pay some or all of your bills. You usually pay a co-insurance, or percent of the bill, when you get a covered service. The PPO pays the rest.
Out-of-Network PPO Costs
If you see a doctor or other provider who is not in your health plan's network, you and your plan share the cost of the service. However, your cost will usually depend on the plan's Maximum Allowable Amount for the service. This is the most your plan will pay for a service. It is usually about the same as what the plan pays providers who are in the network.
Before you see an out-of-network provider, you can ask your plan to tell you how much it will pay and how much you will have to pay.
A point of service plan, or POS plan, is a type of managed care health insurance system. It combines characteristics of the health maintenance organization (HMO) and the preferred provider organization (PPO).
An exclusive provider organization (EPO) plan is a network of individual medical care providers, or groups of medical care providers, who have entered into written agreements with an insurer to provide health insurance to subscribers. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care.
Medi-Cal Managed Care Plans (Low or No Income)
Medi-Cal is health care for people with low or no incomes. Some people who have Medi-Cal are in a Medi-Cal Managed Care plan. These plans have networks of providers, including doctors, pharmacies, clinics, labs, and hospitals. Medi-Cal covers the basic benefits that all health plans cover. Medi-Cal also covers prescription drugs, vision care, and hearing care.
You must use the providers in your network when you need health care.
You will have one doctor or clinic that you go to first for most of your health care. The health plan may choose a doctor or clinic for you when you join the plan. You can change your doctor or clinic if you want. Call your plan and ask for a list of doctors and clinics.
Do I qualify?
There are many ways to qualify for Medi-Cal. Medi-Cal considers both your income and your medical problems. For information, call your county Social Services office or Covered California at (800) 300-1506, TTY: (888) 889-4500.
- If you do not qualify for Medi-Cal, you may be able to get AIM. AIM stands for Access for Infants and Mothers. It is low-cost health care for pregnant women and their infants. To apply for AIM, call 1-800-433-2611.
- If you need mental health care, call your County Mental Health Agency. You can also call the Medi-Cal Mental Health Care Ombudsman at 1-800-896-4042, TTY: 800-896-2512.
Review these additional resources for Medi-Cal information and help.
Medicare Advantage Plans (Seniors or Disabled)
Medicare is a national health insurance program for seniors or those with disabilities. Medicare Advantage is Medicare's managed care program. If you join Medicare Advantage, you get all your care through an HMO or PPO that has a contract with Medicare.
Anyone who has Medicare can get free help with forms, problems, and questions. Call HICAP (Health Insurance Counseling and Advocacy Program) at 1-800-434-0222 or visit the HICAP web site.
The Federal Center for Medicare Services (CMS) regulates Medicare Advantage plans.
Do I Qualify?
- Most people 65 and older.
- Some younger people with disabilities.
- People with End-Stage Renal Disease (kidney failure requiring dialysis or a transplant).
Review these additional resources for Medicare information and help.