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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.
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