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.
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?
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.
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