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How Health Insurance Works

Health insurance plans provide you with financial protection for your healthcare needs. It is often less expensive than paying for care on your own but it often requires help to successfully understand.

Learn about health insurance we accept at RRH.

Types of Health Insurance

Health insurance ensures that you are financially covered for most, if not all, of your medical care depending on which plan you choose. Each month, you make a payment to a health insurer, such as Medicare or your insurance company. Some employers contribute to this payment.

In return, you are covered for all or some of your medical expenses, depending on the plan you are enrolled in, and as long as you follow the insurer's rules. For example, your health insurance plan may only sign contracts with certain doctors and hospitals who then become part of this “network”. If you decide to receive medical care outside this “network”, you risk having your insurer decline coverage.

Government Health Insurance Programs

Medi-Cal:

  • Medi-Cal is California's Medicaid program, funded by the state and the federal government jointly. It provides free or low-cost care to children and adults with low income.
  • Contact: Call 800-541-5555 or visit medi-cal.ca.gov.

Medicare:

  • Medicare is a federal government program that covers people 65 and older, as well as some people with certain diseases or disabilities. Medicare includes Parts A and B (coverage for hospitals and doctors). Part D (prescription drug coverage) is optional and costs extra. You may only join during certain enrollment periods.
  • Contact: Call 800-MEDICARE (800-633-4227) or visit medicare.gov. You may find it easier to contact an outside group for advice. For questions about your options and rights, reach the nonprofit HICAP (Health Insurance Counseling and Advocacy Program) at cahealthadvocates.org/hicap or 800-434-0222. Learn about prescription drug options through our partner, the consultant eHealth, at medicare.com or 877-345-6677.

Health Insurance Through Private Plans

Medicare Advantage:

  • Similar to traditional Medicare, but private companies can offer them. They cover services from doctors and hospitals, and sometimes prescription drugs.
  • Contact: Reach out to the health insurer at medicare.com or 877-345-6677.

HMOs (Health Maintenance Organizations):

  • With HMO plans, including Medi-Cal Managed Care, you can only see doctors and use hospitals within a “network”. You must also choose a primary care physician (PCP). To see a specialist, you first need a referral from your PCP.
  • Contact: Reach out to the health insurance company.

PPOs (Preferred Provider Organizations):

  • With PPO plans, you can see specialists without a referral from a primary care physician. You can see any doctor or use any hospital as long as you stay within your health insurance plan’s “network” of providers and hospitals. Your plan may allow you to receive care out-of-network but may not cover as much of it.
  • Contact: Reach out to the health insurance company.

POS (Point of Service) plans:

  • Description: These plans combine aspects of HMOs and PPOs, with a network of approved doctors and hospitals. Like an HMO, you must choose a primary care physician and secure referrals to see specialists. Like a PPO, there is often some flexibility with going out of network.
  • Contact: Reach out to the health insurance company.

Health Insurance and Out-of-Pocket Expenses

For many, health insurance plans cover a portion of the health care costs but not all of it. Whatever is not covered is known as "out-of-pocket" expenses. Additionally, health insurance can have deductibles, copays, and co-insurance. We advise you to inquire with your health insurance to understand your plan.

Referrals and Authorizations: What You Need To Know

A referral is an order from your Primary Care Provider (PCP) to see a specialist or receive medical services from some providers. Your PCP generally helps make the decision about whether a specialist service is necessary for your treatment.

Authorization (Sometimes called prior authorization, prior approval, or precertification) is the process of getting approval from the health insurance plan before you get a medical service or fill a prescription.

Many health insurance plans now require authorizations before having a procedure done or before scheduling specialty office visits. The requirements may vary from plan to plan, so it is advised to check with your own carrier to determine if authorization is needed.

The authorization request is usually submitted by either the provider or the facility. The response time for a decision varies depending on the type of authorization requested.

It is important to note that when authorization is required, delays might be observed as approval should first be obtained from the health insurance carrier.