Understanding The Different Layers of Protection in California's Health Insurance Market

If you are looking for health insurance for your business, it's easy to become confused by all of the rules and array of different types of plans. Here is an easy guide to understanding the different kinds of health insurance that are available to your employees. 

There are three levels of service available to consumers, and you're probably most familiar with them by their acronyms. Here is a breakdown of each layer of service and how they differ.

Exclusive Provider Organization (EPO)
Many consumers have never heard of EPOs. This plan is similar to a PPO. The tradeoff is they can be costly, and they do limit the amount of help you can get outside of the network.

• You don't have to consult with a primary care physician for referrals, and you can see any doctor within the plan at any time. This means you don't have to wait for referrals for specialists.
• However, you have to use the doctors within the network. You cannot use doctors outside of your EPO network unless it is an emergency.
• If you do go outside of the network, you will have to pay for the services out of pocket.
• Costs vary, you will pay more for the privilege of seeing any doctor you want and cutting out the layers of medical bureaucracy.

Health Maintenance Organizations (HMO)
You are probably most familiar with this level of service.  An HMO is usually the most inexpensive layer of protection however it also has its trade-offs.

• An HMO requires you to have a primary care physician. If you want to see a specialist, you still need to go through the primary care doctor, and the doctor will make the decision.
• If you decide to see a physician outside of the network without getting approved by the HMO plan, you will end up paying the full bill.  
• Some HMOs will limit their coverage to a specific area. If you live outside of that area, you will have to choose a different plan.
• There is copay involved with an HMO.
• If you have specific doctors you like to see,  you may have to stop seeing them if they are not part of the HMO network.

Preferred Provider Organizations (PPO)
A PPO allows you to see specific doctors within the network.  If you go "out-of-network" and see a doctor, you could end up having to pay a portion or the entire bill.
PPO's are a good choice if:

• You have specific doctors you want to see without having to see a primary care physician first.
• You have to provide insurance for kids who are away at college and out of the service range of the HMOs in your area.
• You need specialists for any current and ongoing health issues.

At Culture Insurance we deal with health insurance on a daily basis. We help many San Diego County businesses with choosing the right plans for their employees. Choosing the right plan goes a long way to building a strong relationship with your employees.

If you are considering providing a health insurance plan for your company, we invite you to contact us for a thorough review of your situation and to learn how we can you.