Clovis Health Insurance Agency LLC

Health plans sold in California fall in these three categories. They differ when it comes to things like costs and provider networks (the doctors, hospitals, labs, and so on that your plan covers).

HMOs (health maintenance organizations) are typically cheaper than PPOs, but they tend to have smaller networks. You need to see your primary care physician before getting a referral to a specialist.

PPOs (preferred provider organizations) are usually more expensive. In exchange, you will likely get a larger network and the ability to see a provider outside that network. You can also see specialists without a referral.

EPOS (exclusive provider organizations) combine features of HMOs and PPOs. They have exclusive networks like HMOs do, which means they are usually less expensive than PPOs. But as with PPOs, you’ll be able to make your own appointments with specialists.

Before enrolling in a plan, it is always a good idea to confirm with providers that they accept your plan of choice.

A comprehensive list of free preventive care available in all health plans through us can be found on the Using Your Plan page.

Copays are a fixed out-of-pocket amount paid for covered services. Insurance providers often charge copays for services such as doctor visits or prescription drugs.

Your deductible is the amount you pay out of pocket for health care services covered under your insurance plan before your plan begins to pay for eligible expenses. The amount you pay for a health insurance deductible is determined by the type of plan you choose.

Coinsurance is your share of costs for a covered health care service after the deductible is reached. It’s calculated as a percentage.

A pre-existing condition is any illness or condition a patient has prior to obtaining insurance. In the past, people could be barred from getting a health plan because of a pre-existing condition. Thanks to the Affordable Care Act, pre-existing conditions are no longer grounds for refusing to sell someone insurance.

For some services, copay plans and coinsurance plans will have different costs. With coinsurance plans, you’ll pay a percentage of a certain service; with a copay plan, these services will have set prices. This choice in plans is only available at the Gold coverage level.

Cost-sharing reductions help you save money when you receive medical care. (Financial help, on the other hand, is the savings you get on your monthly premium.) They include savings on deductibles, coinsurance and copays, or similar charges. This type of savings is available with certain health plans.

A health insurance network is a group of doctors and medical care providers across multiple specialties that have a contract to provide health care services to members of a health insurance plan.

When you see a doctor who is in-network, you are using a provider who participates in one of CareFirst’s provider networks. Some health insurance plans only cover care in-network, while other health plans cover both in-network and out-of-network care. If your health plan covers out-of-network care, staying in-network often still reduces the amount you pay for health care.

Out-of-network means that a doctor or physician does not have a contract with your health insurance plan provider. This can sometimes result in higher prices. Some health plans, such as an HMO Plans, will not cover care from out-of-network providers at all, except in an emergency.

The coverage your plan offers for in-network and out-of-network health care providers, and the network your provider is in, both impact how much you pay for care.

If you have an HMO plan, you are only covered for in-network care, except in medical emergencies, when you may receive coverage out-of-network. With a PPO plan, you may have coverage for out-of-network care whenever you choose, but your out-of-pocket cost for out-of-network health care may be higher than for care in-network. Understanding the network coverage your plan has can help you choose which doctors and other health care providers to see, to get the best value for your money.

Medicare Advantage

Medicare Advantage is Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D. Plans may offer some extra benefits that Original Medicare doesn’t cover — like vision, hearing, and dental services. Medicare Advantage Plans have yearly contracts with Medicare and must follow Medicare’s coverage rules. The plan must notify you about any changes before the start of the next enrollment year.

Learn about the types of Medicare Advantage Plans.
Each Medicare Advantage Plan can charge different  out-of-pocket costs. They can also have different rules for how you get services.

Learn more about how Medicare Advantage Plans work.

Medicare drug coverage helps pay for prescription drugs you need. To get Medicare drug coverage, you must join a Medicare-approved plan that offers drug coverage (this includes Medicare drug plans and Medicare Advantage Plans with drug coverage).

Learn more about how to get Medicare drug coverage.

Each plan can vary in cost and specific drugs covered, but must give at least a standard level of coverage set by Medicare. Medicare drug coverage includes generic and brand-name drugs. Plans can vary the list of prescription drugs they cover (called a formulary) and how they place drugs into different “tiers” on their formularies.

Learn more about Medicare drug coverage.

Plans have different monthly premiums. You’ll also have other costs throughout the year in a Medicare drug plan. How much you pay for each drug depends on which plan you choose.

Learn about your costs for Medicare drug coverage.

When you have other insurance, there’s more than one “payer” for your coverage.
Learn how Medicare works with other insurance.