Choose the Right Plan

Choose the Right Plan

When considering health insurance there are several things to consider before obtaining a plan.

Most people in California are required to have health coverage. If you do not have health coverage you may have to pay a tax penalty. This is called the “individual mandate.”

Your benefit package includes all the benefits, or services, your health plan covers.

Premium costs and out of pocket costs differ from plan-to-plan. As you compare costs, look at the benefits as well as the costs. Plans with lower premium costs may end up costing you more if the plan does not cover what you need.

The quality of care differs from plan-to-plan. Providers are typically rated in the areas of clinical performance and patient experience. You should check to see if your providers are contracted with the health plan you are considering.


Individual Mandate

Most people in California are required to have health coverage. If you do not have health coverage you may have to pay a tax penalty. This is called the “individual mandate.”

A person meets the individual mandate if they have health coverage that meets the definition of “Minimum Essential Coverage.” Federal and California law define Minimum Essential Coverage the same way.

You can learn more in the DMHC Frequently Asked Questions (FAQs) on minimum essential coverage for California Individual Mandate law.

Understanding Benefits

California law states that health plans must provide many basic health care services, and certain other services. Plans must only provide services when the services are medically necessary. A definition of what is medically necessary can be found in your health plan contract, i.e., Evidence of Coverage.

Basic services include doctor and hospital services. Health plans must cover inpatient services—when you have to stay overnight in the hospital. They must also cover outpatient services, such as minor surgery in a surgery center. Other basic services are:

  • Laboratory tests to diagnose problems. These include blood tests, STD (sexually transmitted diseases) tests, pregnancy tests, and some cancer screening tests.
  • Diagnostic services, like x-rays and mammograms
  • Preventive and routine care, like vaccinations and checkups
  • Mental health care for some serious problems
  • Emergency and urgent care even if you are outside your health plan's service area
  • Rehabilitation therapy, such as physical, occupational and speech therapy
  • Some home health or nursing home care after a hospital stay
  • Standing referrals for patients with AIDS (This means that you do not have to get a referral and approval each time you see an AIDS specialist.)
  • Diabetes services and supplies
  • Routine costs of clinical trials for cancer treatment
  • Prosthetic devices or reconstructive surgery after a mastectomy (removal of a breast)
  • Prosthetic devices to restore a method of speaking for a patient after a laryngectomy (removal of the vocal cords). This does not include electronic voice producing machines.
  • Reconstructive surgery to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. The purpose of the surgery must be to improve function (the way a part of the body works) or to create as normal an appearance as possible.
  • Services related to diagnosis, treatment, and management of osteoporosis (weak bones), including bone mass measurement and other FDA-approved tests and medications
  • General anesthesia for dental procedures in certain cases

Most medical health plans do not cover dental care, eyeglasses, and hearing aids. Only some plans cover durable medical equipment. What is covered will differ from plan-to-plan.

Understanding Costs

The costs of health care in an HMO, PPO or EPO can be hard to understand. A health plan may sell different products with different benefits and costs. Some health plans and employers have on-line tools and calculators to help you decide which plan is best for you.

Ask About Costs Before You Join a Health Plan

Talk to your employer, insurance broker, Covered California or call the plan directly.

  • What is the monthly premium? (The amount that you or your employer pays each month).
  • What is the yearly deductible? (The amount you have to pay each year before the plan starts to pay).
    • Is there a separate deductible for different kinds of services? (For example, one deductible amount for prescriptions and a different deductible amount for other medical services).
    • What costs (e.g., co-pays or co-insurance) or services (e.g., hospital, surgery) apply towards the deductible?
  • What is the yearly out-of-pocket-maximum?
    • This is the total you have to pay each year for most of your covered services. It does not include your premiums. Each family member has a yearly out-of-pocket maximum, and there may be a family out-of-pocket-maximum also. When an individual or family reaches the maximum, they do not have to pay most out-of-pocket costs for the rest of the year.
    • Ask what costs (e.g., co-pays, co-insurance, deductibles) apply towards the yearly out-of-pocket maximum.
    • What is the co-pay or co-insurance that you pay
      • When you have an office visit?
      • For prescription drugs?
      • For a hospital stay?
      • For an emergency room or urgent care visit?

Are there dollar limits on your coverage?

  • In 2014, yearly limits for benefits ended. Some benefits, that are not considered basic or essential, may still be limited.
  • Most health plans cannot put a lifetime dollar limit on your benefits. This means that if you have a serious and costly illness, you can still get care. You will not run out of coverage.
  • Some benefit that are not considered basic or essential, may still be limited.
  • You may have to pay a significant portion or the whole bill if:
    • You see a specialist without a referral from your primary care doctor and prior approval from your medical group or health plan.
    • You see a provider who is not in your health plan's network, unless it is an emergency or you have a referral and prior approval. The network is all the doctors, hospitals, and other providers who have contracts with your plan to provide care to plan members.
    • You go to an emergency room for non-emergency care.
    • You get care outside your health plan's service area, unless it is emergency or urgent care.
    • You fill a prescription for a drug that is not on your health plan's list of approved drugs or you fill your prescription at a pharmacy outside your plan’s network.
    • You get services that are not part of your benefit package.
    • You get services that are determined to be experimental/investigational or not medically necessary.

Be aware of Premium Rates

The DMHC is committed to providing the public with information in order to expand consumer understanding about rate increases and promote more accountability within the health care industry.

Quality of Healthcare

The quality of care differs from plan-to-plan. The HMO Report Card can help you compare the quality of care for HMOs and medical groups in California. The Report Card provides information on the quality of different types of healthcare and on how patients rate their experience getting care.