Health Care Quality Report Card
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About Health Insurance Plans

There are many types of health insurance coverage. These are the most common ones:

Group Plan - Many people get their health insurance through their employers. This is called “group” coverage. You pay your insurance premium through your employer – usually a deduction from your paycheck.

Individual Plan - If you are not-employed, not a full-time employee, self-employed, or your employer does not offer health insurance as a benefit, you may be able to buy health insurance directly from the insurance company. This is called “individual” coverage. You pay your premiums either directly to the insurance company or through an insurance broker. Both group and individual coverage are forms of “commercial” or “private” insurance.

Government Plans - Some people may be eligible for government insurance programs. You must meet the program’s eligibility rules and have to apply for this insurance. People who are 65 years and older or people who have disabilities are often eligible for Medicare, an insurance program run by the federal government. Some people who have low incomes may be eligible for the Medi-Cal or Healthy Families programs which are run by the State of California. In some cases, you may be eligible for both Medicare and Medi-Cal.

The Government also provides insurance for its own employees including CalPERS (for public employees in California), the Federal Employees Health Benefits Program, and the Veteran's Administration.

In addition, commercial insurance companies and the government offer different kinds of “products”:

HMO - You may be offered an HMO (health maintenance organization) where you must use the doctors and facilities that are on their list (except in the case of a medical emergency). If you don’t, you will have to pay the entire cost yourself. An HMO may also require you to choose a primary care doctor who will be your main doctor and refer you to specialists if you need them.

PPO - You may be offered a PPO (preferred provider organization). In a PPO, you are encouraged to use doctors and facilities that are on their list. If you use others, you have to pay a higher share of the cost or a larger co-payment.

Fee-for-Service – The government may also offer a “fee-for-service” option. With fee-for-service, you can go to any doctor or facility that “accepts your card”. Both “traditional” Medicare and Medi-Cal offer this option.

It is important to know what type of coverage and product you have because that determines which doctors and facilities are covered by your insurance. Sometimes you can tell what kind of insurance you have by looking at your insurance card. If you still cannot tell, you should call the member services telephone number on the card and ask your insurance company for assistance. The personnel office where you work may also have this information.

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