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 employer. This is called “group” coverage. When you pay your share of the insurance premium it is usually deducted 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, 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. Group plans and individual coverage are forms of “commercial” coverage – these are “private insurance,” not government, plans.

Government Plans - Some people may be eligible for government insurance programs. People who are 65 years and older or who have disabilities often are 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 Federal and State Governments also provide insurance for its own employees including CalPERS (for public employees in California), the Federal Employees Health Benefits Program for federal government workers, and the Veteran's Administration for people who have been discharged from the military and need medical care due to their military service.

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

HMO - You may be offered an HMO (health maintenance organization). In an HMO, you must use the doctors and facilities that are on the HMO’s list of doctors, hospitals and other providers. If you use providers who are not part of the HMO, you will have to pay the entire cost yourself (except for a medical emergency). An HMO also may require you to choose a primary care doctor who will be your main doctor and can 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 the PPO’s list of doctors, hospitals and other providers. If you use providers who are not part of the PPO, you have to pay a higher share of the cost when you get care.

Fee-for-Service – You may be offered a “fee-for-service” insurance plan. With fee-for-service, you can go to any doctor or facility that “accepts your insurance card”. The government programs, Medicare and Medi-Cal, offer this option as do some employers who offer private insurance to their workforce.

It is important to know the type of insurance coverage you have because that determines which doctors, hospitals and and other providers are covered by your insurance and the rules for choosing and using these providers. Sometimes you can tell what kind of insurance you have by looking at your insurance card. If you are unsure, call the member services telephone number on the card and ask your insurance company for assistance. The personnel office in the workplace also should have this information.

310.200