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Most indemnity policies allow you to choose any doctor and hospital that you wish when seeking medical 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 if any geographic limitations. When purchasing an indemnity policy, you may often have a deductible. The deductible is the amount you are required to pay before policy benefits are provided. You may have a choice in the amount of your deductible. If your medical care charges are covered, or eligible for payment under the policy, any applicable deductible will apply. Once the deductible has been paid, the remaining charges are reimbursed to you at a specified percentage according to the policy contract. The difference between eligible charges and the percentage paid is called a "copayment," 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 medical care services and ask your medical 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 medical insurance policy that is a traditional fee-for-service policy issued by a CDI licensed medical insurance company, then you can contact the CDI for assistance. Since jurisdiction is divided between several state and federal agencies, it can be confusing to determine who regulates your medical care coverage. The CDI is always available to assist consumers with medical care questions or to direct consumers to the correct agency for assistance. Please see the last page of this brochure for the many ways you can contact the CDI.
Important Points to Remember About Indemnity Policies:
- You have the freedom to choose your doctor, specialist, or hospital with few if any 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.
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A Preferred Provider Organization (PPO) provides a list of contracted "preferred" providers from which to choose. You receive the highest monetary benefit when you limit your medical care services to those providers on the list. If you go to a doctor or hospital that is not on the preferred provider list referred to as going "out-of-network", then the plan covers a smaller percentage of your medical care expenses or may cover none of your medical 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 medical 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 medical care providers within your PPO network, if applicable.
PPOs in California can be regulated by either the CDI or the Department of Managed Medical Care (DMHC) depending on whether the underwriting company (the company backing the policy) is a licensed insurance company or a managed care company. The DMHC has sole jurisdiction over Blue Cross/Blue Shield PPO medical plans. If you are confused about whom to call regarding a PPO problem or concern, then consult your plan documents for regulatory information. If there is still some question, then you can reach the CDI or the DMHC for assistance at the contact information given in the "Resources" section of this brochure.
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.
- You should consider checking if your doctor or any specialist referred to you is part of the PPO network before utilizing covered services.
- You can seek the assistance of the DMHC on all Blue Cross/Blue Shield PPO medical plans.
- You can contact either the CDI or the DMHC for clarification regarding PPO issues.
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Membership in a Health Maintenance Organization (HMO) requires plan members to obtain their medical 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 medical 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 medical care services while maintaining quality medical care by specifying provider choice. HMOs offer access to a comprehensive package of covered medical care services in return for a prepaid monthly amount (premium). Most HMOs charge a small copayment depending upon the type of service provided.
All HMOs in California are regulated by the Department of Managed Medical 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 "Resources" section of this brochure.
Important Points to Remember About Health Maintenance Organizations:
- You must obtain medical 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 copayment each time you utilize an HMO covered service.
- You can seek assistance from the DMHC on all HMO and managed care questions.