There are many types of health coverage such as PPOs, EPOs and HMOs. Each one is a little different. Read below for more information.
Preferred Provider Organizations (PPOs)
Which doctors, hospitals and other providers can I use?
You can see "preferred" providers or "out-of-network" providers
- A PPO has a network (or group) of preferred providers. You pay less if you go to these providers. Preferred providers are also called in-network providers.
- With a PPO, you can go to a doctor or hospital that is not on the preferred provider list. This is called going out-of-network. However, you pay more to go out-of-network. The PPO pays less or nothing at all.
- When you are shopping for insurance, be sure to ask what hospitals, doctors, and other providers are "preferred" or "in-network".
What are my costs if I have a PPO?
- Cost can vary. It depends on the providers you go to. If you stay in the PPO's preferred provider network, your costs are less.
- If you choose to go to a provider outside the PPO network, you pay much more. Before you see an out-of-network provider, check with your PPO to find out what is and what is not covered.
Where can I go if I have a problem?
- If you have a PPO, and have a question or want to file a complaint, visit our Consumer and Provider Health Inquiries and Complaints page or call 1-800-927-4357 (HELP).
- Providers can also get help on our Health Provider Complaint page for complaints about things like improper denial of claims or payment delays.
- In some cases, Department of Managed Health Care (DMHC) regulates PPOs. For those, you will need to contact DMHC for help.
- If you are not sure who to call, contact the California Department of Insurance at 1-800-927-4357 (HELP) or visit our Consumer and Provider Health Inquiries and Complaints page and we will help you get to the right place.
Exclusive Provider Organization (EPOs)
Which doctors, hospitals and other providers can I use?
You must use providers in the EPO network.
- Generally, you do not have to use a primary care doctor.
- Most of the time, you do not need to get referrals to see specialists who are in-network.
- EPOs can have many limits on the doctors or hospitals you can use. With an EPO, you can use the doctors and hospitals within the EPO's network. However, you cannot go outside the network for covered care.
- If you do go out-of-network, your EPO will not pay for any services. The only exception is if you have an emergency or urgent care situation.
What are my costs if I have a EPO?
Cost can vary. It depends on the providers you see. If you stay in the EPO's preferred provider network, your costs are less because you will be reimbursed for the health care you get. Like PPOs, you pay a percentage of every medical bill up to a certain level.
If you decide to see a doctor outside the EPO network, you must pay for the full medical bill.
Where can I go if I have a problem?
If you have a EPO, contact us for help.
In some cases, the Department of Managed Health Care (DMHC) handles EPOs. For those, you will need to contact DMHC for help. If you are not sure who to call, call our Hot Line (1-800-927-4357). We will help you get to the right place.
Health Maintenance Organizations (HMOs)
Which doctors, hospitals and other providers can I use?
You must use providers in the HMO network.
- Usually, you must have a primary care doctor. This doctor provides your basic care and makes referrals to specialists.
- If you see a provider outside of your HMO's network, they will not pay for those services (except in the case of emergency and urgent care).
- The doctors and other providers may be employees of the HMO or they may have contracts with the HMO.
- To join an HMO, you must live in the area the HMO services. Outside this area you can only get emergency or urgent care.
What are my costs if I have an HMO?
Usually you pay a flat co-pay each time you see a doctor or fill a prescription. You may also pay a co-insurance for some services. Co-insurance is a part or percentage of the cost, such as 20%.
Where can I go if I have a problem with my coverage?
If you have an HMO, visit the DMHC's web page or call their Help Center at 1-888-466-2219.
Side-by-side Comparison
We have provided a side-by-side comparison of some of the features of these three types of health insurance.
