What is a ppo insurance

There are many types of health coverage such as PPOs, EPOs and HMOs. Each one is a little different. Read below for more information.

Preferred Provider Organizations (PPOs)

Which doctors, hospitals and other providers can I use?

You can see "preferred" providers or "out-of-network" providers

• A PPO has a network (or group) of preferred providers. You pay less if you go to these providers. Preferred providers are also called in-network providers.
• With a PPO, you can go to a doctor or hospital that is not on the preferred provider list. This is called going out-of-network. However, you pay more to go out-of-network. The PPO pays less or nothing at all.
• When you are shopping for insurance, be sure to ask what hospitals, doctors, and other providers are "preferred" or "in-network".

What are my costs if I have a PPO?

• Cost can vary. It depends on the providers you go to. If you stay in the PPO's preferred provider network, your costs are less.
• If you choose to go to a provider outside the PPO network, you pay much more. Before you see an out-of-network provider, check with your PPO to find out what is and what is not covered.

Where can I go if I have a problem?

Exclusive Provider Organization (EPOs)

Which doctors, hospitals and other providers can I use?

You must use providers in the EPO network.

• Generally, you do not have to use a primary care doctor.
• Most of the time, you do not need to get referrals to see specialists who are in-network.
• EPOs can have many limits on the doctors or hospitals you can use. With an EPO, you can use the doctors and hospitals within the EPO's network. However, you cannot go outside the network for covered care.
• If you do go out-of-network, your EPO will not pay for any services. The only exception is if you have an emergency or urgent care situation.

What are my costs if I have a EPO?

Cost can vary. It depends on the providers you see. If you stay in the EPO's preferred provider network, your costs are less because you will be reimbursed for the health care you get. Like PPOs, you pay a percentage of every medical bill up to a certain level.

If you decide to see a doctor outside the EPO network, you must pay for the full medical bill.

Where can I go if I have a problem?

If you have a EPO, contact us for help.

In some cases, the Department of Managed Health Care (DMHC) handles EPOs. For those, you will need to contact DMHC for help. If you are not sure who to call, call our Hot Line (1-800-927-4357). We will help you get to the right place.

Health Maintenance Organizations (HMOs)

Which doctors, hospitals and other providers can I use?

You must use providers in the HMO network.

• Usually, you must have a primary care doctor. This doctor provides your basic care and makes referrals to specialists.
• If you see a provider outside of your HMO's network, they will not pay for those services (except in the case of emergency and urgent care).
• The doctors and other providers may be employees of the HMO or they may have contracts with the HMO.
• To join an HMO, you must live in the area the HMO services. Outside this area you can only get emergency or urgent care.

What are my costs if I have an HMO?

Usually you pay a flat co-pay each time you see a doctor or fill a prescription. You may also pay a co-insurance for some services. Co-insurance is a part or percentage of the cost, such as 20%.

Where can I go if I have a problem with my coverage?

If you have an HMO, visit the DMHC's web page or call their Help Center at 1-888-466-2219.

Side-by-side Comparison

We have provided a side-by-side comparison of some of the features of these three types of health insurance.

>>>Next: Health Insurance Benefits

Page 2

No one plans to get really sick or hurt. But when it happens to you or your family, it can cost a lot of money to get care. Health insurance can protect you from these high costs. If you buy health insurance, it can easily cost you less money than going to the hospital without it. Health insurance also helps you get regular health care. That way, you can get healthy and stay healthy.

But health insurance still costs money and choosing the right policy for you can be hard. What if you already have insurance? The information below can help you understand the policy you already have and help you when you are shopping for new coverage.

Overview: Healthcare Coverage in California

Find out more how healthcare coverage works in California

Types of Health Coverage

Explore the different types of health coverage like PPOs, EPOs, and HMOs and the differences between them.

Health Insurance Benefits

Learn about the kinds of benefits to expect when you have health insurance.

Health Insurance Costs

Learn more about the cost of health insurance including things like co-pays, co-insurance, deductibles, and premiums.

The Affordable Care Act

The Patient Protection and Affordable Care Act was signed in 2010 by President Obama. Visit this page to learn more about what these changes mean for you.

Medicare and Medicare Supplement for Seniors

Learn more about Medicare and Medicare Supplement coverage options for seniors and who to turn to when you have questions or need help.

Common Health Insurance Terms

Health insurance can be confusing and complicated, with lots of new terms and definitions so we put this page together to help you!

Health Insurance Regulation

Learn more about what governmental agency regulates which type of insurance policies so you know where to go when you need help.

Other Health Resources

Find a variety of health resources

Getting Help

Visit our help page to learn who to contact for help with your health insurance policy.

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If you have lost your coverage or your coverage is going to end there are many options for you. It all depends on what type of coverage you just lost or are about to loose. Below are some options that may be helpful to you:

I have Employer-Based Coverage

If your employer-based coverage is ending, you have several options:

Continuation Coverage programs include COBRA, Cal-COBRA, and HIPAA. These programs allow you to extend your employer-based coverage for a certain amount of time.

You can also shop for new coverage on the individual/family market.

I have Individual/Family Coverage

If you bought an individual/family policy (either directly from an insurer, through an agent or broker, or through Covered California), there are very few ways in which your insurer can rescind or cancel your coverage. Insurers can rescind your policy if you intentionally misrepresent material facts on your application.

Insurers can cancel your policy if you do not pay your premium. However, you have a 30 day grace period before insurers can cancel your policy. Insurers must give you 30 days notice by mail if they are going to cancel your insurance policy.

If an insurer sent you a policy cancellation letter, and you disagree with their reason for cancelling your policy, contact us at 1-800-927-4357 (HELP) or visit or online Consumer Hotline for help.

Page 4

Choosing the right health insurance for you and your family or your small business is important. But it is not always easy. There are many different types of coverage. Here is some information to get you started. The Health Insurance Basics section may also help you.

We divided health coverage into these three categories:

Group Coverage

Group coverage is sold to employers or other groups. This is what you get when you get health coverage through your job. Employers usually pay for some of the premium each month. Employees may also need to pay for some of the premium. There are two types of group plans: one for small employers and one for large employers.

Shopping for Individual/Family Coverage

In this type, individuals buy coverage for themselves or their family. You can buy coverage from an insurance company directly, a licensed insurance agent, or through Covered California, California's health insurance marketplace.

Public Programs

These are low or no-cost programs for people who qualify based on income or other factors. Medi-Cal is one example.

Considerations When Purchasing Health Insurance

Four things you should think about when choosing coverage - costs, provider network, benefits, and quality.

Health Insurance Report Card

Our Health Insurance Report Card will allow consumers to compare PPOs in a number of key areas such as Diabetes Care, Treating Children, Heart Care and others.

Health Insurers in California

We provide a list of insurance companies licensed to provide health insurance coverage in California.

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Page 6

Google™ Translation Disclaimer

This Google™ translation feature is provided for informational purposes only.

The Department of Insurance is unable to guarantee the accuracy of this translation and is therefore not liable for any inaccurate information resulting from the translation application tool.

The Department of Insurance is also unable to guarantee the same page layout for all the languages. Depending on the languages, the page layout may look strange from the original.

Please consult with a translator for accuracy if you are relying on the translation or are using this site for official business.

A copy of this disclaimer can also be found on our Disclaimer page.

Select a Language Below / Seleccione el Idioma Abajo

Close this box or use the [X]