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WHAT DOCTORS CAN I SEE WITH CALIFORNIA GROUP HEALTH INSURANCE?
Welcome to the Doctor and Provider  page.  You will find access to online provider directories for all major California group carriers.


CALIFORNIA GROUP HEALTH INSURANCE
 -For all major carriers, click below.

    
                           
CALIFORNIA INSURANCE DOCTOR DIRECTORY

What is the difference between HMO and PPO?

Where can I look up my doctor?

Which carriers have the best networks in California?

What if my doctor is not in the network?

Can I change doctors later?

Do I need to choose a doctor before enrolling?

What about out of State employees?

What is the difference between HMO and PPO?

HMO...PPO...EPO???  What does it all mean.  Well... rather than give you the long version of each term, let's get to the heart of what each is, and more importantly, how it affects your employees.

First a stroll down medical memory lane.  Up until the mid 80's (wow...last century), California Group health insurance was pretty straight forward.  You can go to any doctor and the insurance company is going to pay a certain amount.  It was around this time however, that they came up with "managed care".  And voila, terms like HMO, PPO, and EPO made their entrance.  Well what are they?

They are essentially volume discounts.  

In order to control costs, the insurance company went to doctors and said, "Look.  If you join our PPO, we'll bring you a lot of customers (us the insured) but we want you to discount your costs 30-60%.  That $100 doctor visit should be $60.  And if you join our HMO, we'll pay you $50/month for each person who signs up with you.  In turn, there will be a lot of people to make up for this discounted amount.

Now there are variations in a contract between insurance companies and doctors, but essentially, they are offering volume discounts to help contain medical cost inflation...and it worked!!  From the early 90's to about 1997...all was relatively calm on the insurance premium front.  We may have reached the extent of what managed care can do as premiums have risen significantly since 1998.

Now that we have a behind-the-scenes view of what HMO, PPO, and EPO are from a doctor point of view...how do they affect us??

First let's break each one down.  
If the old way (Fee for Service) was that you can go to any doctor you wish, then the
HMO (Health Maintenance Organization) is the polar opposite.  You choose one doctor up front, and essentially all care is managed through that doctor and with a local hospital and medical group.  This doctor is referred to as a Primary Care Physician and he or she makes most decisions on care and/or referral to quotes.  The trade-off with this highly structured system is that the benefits are very rich...i.e. low out-of-pocket expense when you get sick or hurt.  Some people swear by it...others swear at it.  It works for people who are flexible and want low-out-of-pocket expense.  You typically do not find HMO's available in rural areas...because remember, they need lots of people to make it work.

Back to our spectrum, the
PPO's (Preferred Provider Organization) are somewhere in between the "go to any doctor" method of the past and HMO's "choose one doctor/hospital". There is an extensive list of doctors and hospitals in California from which you can go to.  You refer yourself out to quotes and  you are not locked into one area or one doctor.  You receive the negotiated rates (30-60% discounts mentioned above) with a PPO plan which can amount to significant savings.  That being said, you will help pay along the way...either in the form of a percentage or a deductible (we'll get into these in section 4).  Now with PPO's, you can go to doctors who are not in the network but then your benefits are significantly reduced.  Why??  These doctors are not offering the "volume discount" we mentioned above.

Another variation not as often seen is an EPO (Exclusive Provider Organization).  An EPO has the exact same doctors/hospitals as the PPO list but with no out-of-network benefits.  If you go to a doctor not listed on the EPO list, you have no benefits.  

Some more interesting facts for
California Group health insurance networks:

In a true emergency (and be very conservative on this definition...it better be serious!!), your benefits will likely cover you even out of the above networks.
Sometimes doctors participate in HMO and PPO...sometimes just one of them.  You can verify your doctor's participation
here under "provider".  

This HMO or PPO question is really the big one to answer for your employees first if possible.  Ideally, you offer something like Blue Cross of California "Employee Elect" which allows a full range of HMO and PPO plans. 

You can always ask us to explain further the differences between the two.

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 Where can I look up my doctor?

Click the link below to look up your doctor:

CALIFORNIA INSURANCE DOCTOR DIRECTORY

Sometimes, it is just easier to call your doctor's office and ask them if they participate in a given carrier's network.  For example, "Do you participate in Blue Cross's PPO network".  Make sure to specify PPO or HMO as some doctors will participate in one but not the other.

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Which carriers have the best networks in California?

The carrier with the best network is one that has your doctors.  That being said, there are some difference between the carriers.  We will list out the major carriers here:

Carrier by Carrier in descending order (according to Plan Satisfaction Criteria)


Blue Cross of California
Blue Cross is owned by Wellpoint, which is probably the dominant carrier nationwide in terms of stability and progressive plan design.  They are known as Anthem Blue Cross Blue Shield or Unicare in most other States.   They have been the ones to beat in the California health market.
   
   Network
- For PPO plans, they probably the most extensive network with providers in all counties.  Over 70K providers and 400 hospitals State-wide plus access to the Blue Card network for employees in other States.
 

Blue Shield of California
Blue Shield of California a strong carrier in California and also participates in the Blue Card network for out-of-State employees.  It is one of the few non-profits.  Cross and Shield are two separate, completely independent carriers at the Small Group level (2-50 employees).  If PPO needs to be an option or employees are out of State, they are a good comparison for Cross and Health Net.
 
      Network - For PPO plans, they probably rival Blue Cross with providers in all counties.  They probably do negotiate as well as Blue Cross but may have a better reception from doctors/hospitals because of it.  This also affects their pricing going forward.  They do allow access to the Blue Card network for employees in other States.  Their HMO is comparable to Cross.
 

Health Net of California
Health Net of California was originally Blue Cross' HMO many years ago.  Traditionally, they were a strong HMO carrier but they have aggressively moved into the PPO market as the future of HMO's and its cost structure dimmed.  They tend to copy Cross' moves in the market so at least they are smart enough to the follow the leader.  If a company's main focus is HMO and they do not have employees out of State, Health Net is definitely to be considered.
 
    Network - Health Net has a strong HMO network as that has been their bread and butter long before the PPO came along for them.  The PPO network should be well represented throughout the State although it's range probably does not match Cross or Shields, whose experience in the PPO market goes back decades.

Kaiser of California
Kaiser of California is a very large carrier in California and it is structured quite differently than the other carriers.  Kaiser does not contract with independent medical groups and hospitals but actually owns its own hospital and employs its own doctors.  Kaiser is by definition an HMO in that you must remain in their network to be covered.  They have recently offered a PPO plan but their strong suit is HMO. 

Network
- Again, for HMO, they have many facilities (although not in all areas) but tend to work best in more populated areas around cities and larger metropolitans.  You are unlikely to find a facility in more rural areas and out of State can be difficult.   Keep in mind that if your employees are currently not in Kaiser, they will not be able to keep their current doctors.  You're either part of Kaiser or not.  Some people love Kaiser while other do not (to put it mildly).
 
We have listed Blue Cross of Calfornia, Blue Shield of California, Health Net of California, and Kaiser separately as they really are the strongest carriers.  There are many other options on the market, but from our experience, they usually are advisable against one of the above mentioned four. 

Pacificare is a strong carrier but they were recently purchased by United.  Until this transition runs its course, we are hesitant to recommend them.  They are traditionally a strong HMO carrier with only recent PPO plan options.  Their pricing tends to be expensive for PPO's and comparable to Health Net.

Aetna tends to be too expensive and its networks are not as good as the above carriers.  They went the other direction when other carrier decided to compete regionally and tried to offer a truly nationalized plan.  The problem is that they are not as competitive in terms of network, plan offering, ease of use, and ultimately because of this...not as price competitive.  Cigna also falls in this category of "Nationwide plan that's not at competitive in any one region".  United, although a very well run nationwide company (comparable to Wellpoint), also offers a separate suite of group plans in addition to its recent Pacificare aquisition.  Again, until the dust settles on that acquisition and their networks and pricing both stabilize, we would recommend one of the top four carriers. 


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 What if my doctor is not in the network?

iYou want to make sure you are looking at correct type of plan (i.e. HMO vs PPO).  I would also call the doctor's office if they do not show in the online directory as some doctors bill and are listed under medical groups. 

For a PPO plan, if you stay with the same doctor, you will pay significantly higher amounts out of pocket when seeing that doctor except for a true emergency.  For this reason, it's best to go with a doctor that is on the plan.  Always check with doctors and facilities to make sure they are in-network.  This helps you avoid unexpected out of pocket expenses. 


For HMO's, you will need to choose a doctor that participates as there are no benefits outside of your chosen medical group and/or primary care physician.

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Can I change doctors later?

With  a PPO plan, you do not need to use a Primary Care Physician (HMO plan gate-keeper) so you can change around at any time.  Just make sure any new providers also participate in the network.  With an HMO plan, you can request a change of your Primary Care Physician if you are not in a course of treatment.  The change will occur the 1st of the month following approval. 

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Do I need to choose a doctor before enrolling?

With  a PPO plan, you do not need to choose a Primary Care Physician (HMO plan gate-keeper) and so no doctor code is needed for the application or enrollment.  You refer yourself out and your only concern is that any prospective providers participate in the PPO network.

With an HMO plan, you will need to choose a Primary Care Physician and/or medical group before enrolling.  Their code will be entered on your application at the time of applying for coverage.  You can find the code through our online
CALIFORNIA INSURANCE DOCTOR DIRECTORY.

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What about out-of-State employees?

If you have out-of-State employees, HMO plans will not be available to them.  We would strongly recommend Blue Cross of California or Blue Shield of California in this situation as they are the only carriers with a truly nationwide (PPO) network.  They both participate in the
Blue Card program
which extends benefits to any BCBS carrier in other states.  In most states, BCBS is the dominant (if not only) carrier of importance.

With Cross' Employee Elect, you can offer the full range of HMO/PPO plans to employees in California and offer PPO's to out of State employees.

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