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Group Coverage: Information for Employees

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Group Coverage: Information for Employees
Here are some things that you should know about your employer-based coverage
Your employer may offer one group policy or several.
You may have to pay part of your premium.
You may pay all of the premiums for your dependents if your employer offers dependent coverage.
Employers cannot impose a waiting period for coverage on new employees.
Ask your employer about the deadline for choosing health coverage.
Each year, usually in the fall, employers have an open enrollment period. This is when employees can sign up for or change their coverage for the next year.
If your employer offers more than one policy, you can only change it:
during open enrollment; and
if you have certain life events such as moving to a new state, getting married or having a child. 
How do I choose between plans?
Start by asking these questions:
What are the costs?
Which providers and doctors can I see?
What are the benefits?
What is the quality?

Considerations When Purchasing Health Insurance
Fortunately, the Affordable Care Act (ACA) makes it easier to get the right health coverage. All health insurance companies in California sell policies with a standard set of benefits (Essential Health Benefits) and fixed cost sharing (except for grandfathered plans). This makes it easier for consumers to shop for health coverage. It's like comparing apples-to-apples.
Some insurers also offer an alternate plan design. These may have more benefits and the cost sharing may vary.
Below are four things you should think about when choosing coverage - Costs, provider network, benefits, and quality.

When you buy individual/family coverage, your monthly premiums vary based on a few factors including your age, where you live, the number of persons covered, and how much of your coverage you will pay for out-of-pocket. It can be hard for consumers to pick which cost sharing is best for them.
Premiums are calculated differently if you are getting your coverage from your employer (group coverage). Sometimes employers will provide many plans for you to choose from with different levels of cost-sharing. 
You also may have a choice between an PPO, EPO and HMO. 


Which doctors and other providers can I go to?
How large is my provider network?
Can I see any provider in the network?
Is my current doctor in the network?
If I need to choose a new doctor, are there doctors in my area accepting new patients?
Will I need a referral from my doctor to see a specialist?
Does the plan have hospitals and pharmacies near me?
Do I need pre-approval (pre-authorization) from the plan for certain services?
If I travel often, what care can I get away from home?
NOTE: If you want to keep or go to a specific provider and/or hospital, check with the insurer. You will need to find if they are a part of the network for the specific product you are buying. Just because a provider is a part of that insurer's network for another plan, it does not mean that he or she will be a part of the plan that you are buying. 

What benefits does the plan offer?
Most insurance policies now offer a standard benefits, making it easier to compare of your choices. 
What quality of care will I get with this coverage? How does it compare to others?
The California Department of Insurance can tell you how a company ranks in complaints. You can find out how long it takes to reach a live person when call your insurer and and how many complaints the company gets.

Every year, CDI shares a report card with quality information about PPOs.The California Office of the Patient Advocate (OPA) also has information on health coverage and provider quality.


Categories PPO EPO HMO
Network You pay less to see providers in your plan's network. These are called preferred providers. You get covered care from the doctors, hospitals, and other providers in your plan's network. You get care from the doctors, labs, and other providers in your plan's network.
Out-of-Network You can go out-of-network, but you pay more. You can go out-of-network, but you will pay the full our-of-pocket costs for the service. The only exception is if you have an emergency or need urgent care. You cannot see providers out-of-network except in an emergency or if your plan gives you pre-approval.
Primary Care Doctor You may not be required to have a primary care doctor. You may not have to use a primary care doctor. You must have a primary care doctor. This is the doctor you must usually see first when you need care.
Referrals You may be able to get many health services without a referral. You do not need to get referrals to see specialists if they are in the EPO's network. You need referrals to see specialists or to get lab tests.
Pre approval You may be able to get many health services without pre-approval. You will need pre-approval from your health plan before you can get any services. You will need pre-approval from your health plan before you can get many health services.

You may have a yearly deductible.

You may also have deductibles for hospital care and prescription drugs.

Care in the network costs a lot less than care outside the network.

You are likely to have higher out of pocket expenses.

You are less likely to have a yearly deductible.

You usually pay a co-pay or flat fee for most services.

You are less likely to have a yearly deductible.

You usually pay a co-pay or flat fee for most services.


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