The costs of health care in an HMO or a PPO can be hard to understand. A health plan may sell different products with different benefits and costs. If you receive health insurance through an employer and you have a choice of health plans, ask the employer for information that compares the costs and benefits of the plans. Some health plans, and employers also have on-line tools and calculators to help you decide which plan is best for you.

Find Out What Your Costs Are Before You Join a Health Plan

Talk to your Insurance Broker, or call the plan.

What is the monthly premium? (The amount that you or your employer pays each month.)

What is the yearly deductible? (The yearly amount you pay for all or some services 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 coinsurance) or services (e.g. hospital, surgery) apply towards the deductible?

What is the yearly out-of-pocket-maximum? (The total you have to pay each year for most of your covered services, excluding premiums. Each family member has a yearly out-of-pocket maximum. There is usually a family out-of-pocket-maximum. Be sure to ask how the out-of-pocket maximum is applied by the health plan.)

Ask about what costs (e.g. co-pays, coinsurance, 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?

What is the co-pay or co-insurance for prescription drugs?

What is the co-pay or co-insurance for a hospital stay?

What is the co-pay or co-insurance for an emergency room visit?

Is there a limit on how much the plan will pay for prescription drugs in one year?

Is there a limit on how much the plan will pay for medical care in one year?

Is there a limit on how much the plan will pay for your medical care over your whole lifetime? (This is called a lifetime limit.)

You May Have to Pay 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 from whom you can get care.

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 the health plan's list of approved drugs or you fill your prescription at a non-contracting pharmacy. (Check with your health plan’s website or member services for a list of contracting pharmacies.)

You get services that are not part of your benefit package

Basic Services

California law says that health plans must provide many basic services, and certain other services. Plans must only provide services when the service is medically necessary.

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, and pregnancy tests. This also includes 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

Other Benefits that Health Plans Must Cover

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 birth defects, developmental abnormalities (something that is not normal in the way a child grows), trauma or injury, 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

Services that Are Not Required

Most medical health plans do not cover dental care, eyeglasses, and hearing aids. Many plans do cover prescription drugs and durable medical equipment, such as wheelchairs and oxygen, but what is covered differs from plan to plan.

Diabetes Services and Supplies

If you have diabetes (insulin-using diabetes, non-insulin-using diabetes, or gestational diabetes), your health plan must cover the following, even if you can get them without a prescription:

Blood glucose monitors and testing strips

Blood glucose monitors designed for people with vision problems

Insulin pumps and supplies needed to use the pump, in certain cases

Urine strips to test for ketones

Lancets and lancet puncture devices

Pen delivery systems for taking insulin, in certain cases

Podiatric devices to prevent or treat foot problems related to diabetes

Insulin syringes

Visual aids, except eyeglasses, to help people with vision problems take the proper dose of insulin

Out-patient training, education, and medical nutrition therapy to help a person with diabetes use the covered equipment, supplies, and medications properly

If your health plan covers prescription drugs, it must cover the following diabetes drugs:

Insulin

Other prescription drugs to treat diabetes

Glucagon