Understanding California Medical Plan Costs

The costs of medical care in an HMO or a PPO can be hard to understand. A California medical insurance company may sell different plans with different benefits and costs. If you receive medical insurance through an employer and have a choice of medical plans, ask the employer for information that compares plan costs and benefits. Some California medical insurance companies and employers also have on-line tools and calculators to help you decide which plan is best for you.

Ask About Costs Before You Join a California Medical Plan

Talk to your employer or call the plan.

• What is the monthly premium? (The amount that you or your employer pays each month.)
• What is the yearly deductible? (The amount you pay for all or some services before the plan starts to pay.)
• What is the co-pay or co-insurance that you pay when you have an office visit?
• What is the co-pay or co-insurance for prescription drugs?
• What is the co-pay or co-insurance for a hospital stay?
• What is the co-pay or co-insurance for an emergency room visit?
• Is there a limit on how much the plan will pay for prescription drugs in one year?
• Is there a limit on how much the plan will pay for medical care in one year?
• Is there a limit on how much the plan will pay for your medical care over your whole lifetime? (This is called a lifetime limit.)

You May Have to Pay the Whole Bill If:

• You see a specialist without a referral from your primary care doctor and prior approval from your medical group or medical plan.
• You see a provider who is not in your medical plan's network, unless it is an emergency or you have a referral and prior approval.
• You go to an emergency room for non-emergency care.
• You get care outside your medical plan's service area, unless it is emergency or urgent care.
• You fill a prescription for a drug that is not on the medical plan's list of approved drugs.
• You get services that are not part of your benefit package.

Questions and Answers

• What is a premium?
• What is a co-pay or co-insurance?
• What is a yearly deductible?
• How can I find out how much a service will cost if I have a high deductible?

What is a premium?

A premium is the amount you or your employer pays each month for your California medical insurance. If you get medical insurance through your employer, you may pay part of the premium and your employer may pay part.

What is a co-pay or co-insurance?

These are the amounts you have to pay for a covered medical care service or prescription. In some medical plans, such as an HMO, you pay a co-pay, which is a set amount, such as $10. In other plans, such as a PPO, you pay a co-insurance, which is a percent of the cost of the service, such as 20%.

What is a yearly deductible?

A yearly deductible is the amount you may have to pay for all or some covered medical care services before your medical plan starts to pay. Once you have met your yearly deductible, you pay a co-pay or co-insurance for covered services, and your medical plan pays the rest.

How can I find out how much a service will cost if I have a high deductible?

Ask your doctor for the procedure code for the service you need. Then, call your medical plan and ask the cost for this service. Some plans with high deductibles post the costs of common services on their websites. Be sure to ask about the cost of the doctor and the hospital services.