Any illness or any injury leads us to our financial difficulties especially due to increase in cost of medical care over the past 20 years. Medical insurance saves us from these difficulties in cases of injuries and chronic diseases. There are different plans of medical insurance in California. If you are a jobholder, your employer will provide a major medical Coverage or you can buy individual major medical coverage privately or from an insurance agent who is licensed by California State to sell medical products.

Introduction to Medical Insurance in California:

Medical insurance pays all the money that we invest for diagnosis and treatment of covered medical conditions. There are many medical policies in California. Out of them you need to select the best medical policy that fits your medical needs, lifestyle and budget. In case of any problems or difficulties it is advised to have awareness of federal State or agency that regulates your type of policy. There are many advantages and disadvantages in each type of Medical policy. Therefore it would be better for an individual to have knowledge of different medical policies so that he can know how he gets best from his medical policy.

Types of Medical Insurance in California:

Indemnity Policies (Traditional Fee-for-Service Insurance)

Preferred Provider Organizations (PPOs)

Health Maintenance Organizations (HMOs or Managed Care)

Self-Insured Medical Plans (Single Employer Self-Insured Plans)

Multiple Employer Welfare Arrangements (MEWAs)

Indemnity Policies: In this type of policy allows an individual to choose any doctor or a hospital, where he wishes to get the treatment. While choosing this type of medical policy you may often have a deductible. Deductible is an amount which an individual needs to pay before the medical expenses for his treatment gets reimbursed. Once the deductible is paid the eligible charges are reimbursed with a specified percentage as per the medical policy. The difference between amount eligible and percentage paid is termed as co payment. Policy or benefit booklet will tell you what terms and conditions are covered in the booklet and it is advised to go through this booklet before availing any type of medical service and in case of any clarifications contact the agent, company or employer and get that clarified from him.

California Department of insurance regulates indemnity policies. Since the jurisdiction is divided into several federal and state jurisdictions it may be confusing for you to determine who regulates your type of medical coverage. In this type of cases CDI is available to assist customers for their medical queries and direct them to the correct agency.

Points to be remembered regarding indemnity Policies:

• In indemnity policy an individual has the choice to select the doctor, hospital where he wishes to get the treatment with some geographical limitations.

• You are responsible to pay the deductible before the medical coverage policy gets reimbursed

• You need to pay the Co payment for availed medical services.

• You can seek the advice of CDI in case of any discrepancies.

Preferred Provider Organizations(PPOs)

In Preferred Provider Organization an individual is provided with names of contracted preferred providers from which he need to choose. In this type of policy you can get maximum monitory benefit if you choose a preferred Provider. In this type of policy you get a small percentage or no percentage if you choose any other hospital or doctor other than these preferred providers. Individual should be aware of the preferred hospitals in the list to get maximum benefit

PPOs in California are either managed by CDI or by Department of Managed Medical Care(DMHC). If you have any PPO problem or concern you can contact your plan documents for regulatory information. If the problem still persists you can reach either PPOs or DMHCs for further details.

Points to be remembered about PPO Medical plan:

• You need to choose with in PPO network to get maximum benefit.

• You can also go outside the network, it is considered as out of Network and you will get small or no medical expenses.

• You need to check whether the doctor or specialist referred to you is with in the network

• You can seek the advice of DMHC for PPO issues

Health Maintenance Organization(HMO)

HMO plan requires plan members to get the service from doctors or specialists affiliated with HMO. Plan member chooses a primary physician with in the HMO network who treats and directs medical care decisions. The main objective of this HMO plan is to maintain less costly medical care and maintain high quality medical care. Since this HMO is restricted to geographical area this would limit the plan members outside the HMO coverage area. In case of emergencies California HMOs should cover the medical cases even though it is out of the coverage. In HMO policy you need to pay a monthly premium to get access to maximum coverage. Most HMOs charge little Co payment depending on the service provided.

All HMOs in California are managed by Department of Managed Medical Care(DMHC).

Points to be remembered in HMO plan:

You must obtain treatment from directed physicians in HMO except in cases of Emergency

You need to careful in your choice of physician as he directs your care

You will charged little co payment every time you utilize HMO plan

You can seek advice from DMHC on all HMO and managed care questions.

Self Insured Medical Plans

Self Insured medical Plans generally gained popularity in groups for example large employers, labor union etc. These groups provide a pool of money to serve their employees in case of any medical discrepancies. These self Insured Medical plan turn over their medical administration to Third party Administrators. TPA handles processing and payment of these claims.

These Medical plans fall under Employee Retirement Income Security act. This is a federal law governed by U.S Department of labor , Employee benefits Security Administration(DOL EBSA). DOL- EBSA is available to answer questions about self-insured employer plans that fall under ERISA regulation.

Multiple Employer Welfare Arrangements(MEWAs)

MEWA is a trust fund created by members of trade, profession etc. for the purpose of providing medical care benefits to their employees. At present there are less than 10 MEWAs operating with CDI certificate of compliance For any queries on MEWA you can contact California Department of Insurance (CDI). Thus California Medical insurance offers many policies for the convenience of the individuals. You can select any of the above listed policies to gain medical benefits.