CALIFORNIA MEDICAL
Guide

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Guide to California Medical Insurance

Owning health insurance in California is essential to protecting the financial well being of the consumer as well as the literal health of an individual or family.  Given the current strained economic climate combined with the dramatic increases in the cost of medical insurance over the last ten years.  We’ve seen double digit percentage rate increases for over a decade, well past the rates of overall inflation. 

You may be insurance on a California health insurance plan through an Employer, or if you are self employed or your Employer does not offer health insurance you are responsible for obtaining your own health insurance plan.  There are many different potential types of insurance plans, some much more popular than others, described as follows below.  Many of these plan types are available for instant quoting on our website here.

-PPO or Preferred Provider Organization:  under the PPO model a health insurance company contracts with providers who are employed independently.  The member receives the best coverage when visiting the contracted providers.  The member can also visit providers, who could range from a very wide variety of type but include doctors, hospitals, facilities, therapists, and alternative care practitioners.  A member can also visit out of network, or non-contracted providers.  This can be a sticky situation as you will not longer receive discounted or negotiated contract rates for medical services.  The PPO plan will cover the limits of the contracted rate and then the member can be billed for any charges in excess of these amounts.  You will also see very clearly defined reduced benefits in your coverage contract beyond the lack of contracted rates for services.

-HMO, or Health Maintenance Organization:  through the Health Maintenance Organization system a member receives all care through a single medical group which contracts with doctors, hospitals, and facilities to provide care.  The HMO plan may also employee the doctors and own the facilities or contract with them independently.

-Indemnity:  Indemnity coverage is where the insurance carriers will pay providers in any geographic area without any contract or provider network.  It provides the flexibility of the PPO plan without the limitations of the provider network.  Typically an Indemnity policy with have a limitation on the reimbursement amounts to the providers per procedure or expense type.  Indemnity policies can be very expensive due to the lack of negotiated rates for services.  

-Self Insured:   Self insured coverage is where an employer funds all or partial of a plan benefit policy for its employees.  These plans are subject to Federal ERISA regulation.  A Third Party Administrator is brought in to manage the claims built either under a deductible if there is an insurance carrier coverage major or catastrophic bills, or for the claims in their entirety. 

Some important items to remember when considering what path to take when purchasing health insurance in California:

-individual and large employer sponsored coverage uses medical underwriting to determine eligibility, so you can be declined for coverage.

-if you’ve had prior insurance try not to let it lapse or you may face a ‘pre-existing condition waiting period’ on your new insurance plan.

 

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