Plan Type

The private marketplace offers a choice of plan types in most every county or region in CA. Plan types include PPO, HMO and EPO and are a factor in determining premium, healthcare delivery, and most importantly, provider access. Here is a summary definition of the types of plan available:

PPO plans (Preferred Provider Organization) allow for direct access to a statewide doctor/hospital network without the need of referrals.* A smaller benefit is provided and a higher out-of-pocket (OOP) is incurred when going to out-of-network (OON) providers. Blue Shield of CA is the only carrier who offers PPO plans in every zip code across the state. HealthNet is the other carrier offering PPO plans in the private exchange in many CA regions.

EPO plans are similar to PPO plans in that they have a statewide network, but typically the network is smaller. They also provide no benefits when seeing out-of-network providers. Anthem Blue Cross, HealthNet and OSCAR offer EPO plans in some CA regions.

HMO plans offer a closed local or regional network of providers. Care is managed by a Primary Care Physician* (PCP) from within a group of providers who refer members to specialists as needed. No benefits are provided when receiving treatment outside the group unless an emergency or authorized. Kaiser, Sutter Health, Blue Shield of Ca, and Western Health Advantage are just some of the carriers offering HMO plans in CA.

It is important to check with your providers directly to confirm their plan participation, even if they show up in searches using carrier search tools. 

HDHP plans (High Deductible Health Plans) are required in order to participate in a HSA (Health Savings Account). They are offered by many carriers and in all plan types (PPO, EPO or HMO) and are generally found in the Bronze and/or Silver plan categories. Click here to learn more about HSAs.

Out of State Coverage: It is important to understand that your health plan will only provide benefits for urgent care and emergency care out of state. NOTE: Beginning January 1, 2019, Blue Shield of Ca removed their BlueCard program from their ACA compliant individual/family health plans. This unique benefit provided access to BC/BS providers of other states at in-network benefit levels for emergency and non-emergency services. It will remain a benefit in some Blue Shield grandfathered plans and most Blue Shield group plans. Check your plan’s Evidence of Coverage to learn more about benefits out of state.

*Primary Care Physicians (PCP): PCPs have been synonymous with HMO plans. A visit to a PCP is required first before seeing a specialist, and members can choose or will be assigned a PCP at time of enrollment. With a shortage of primary care doctors (General, Family and Internists) in the state, it has affected provider access in all plan types.

Prescription Drug Formularies

The high cost of prescription medication is a topic of daily news and directly impacts the cost of your health plan. Carriers use formulary drug lists to control costs. If you take prescription medication it is important to check the drug list of the plan you are considering.

Click on a carrier to check their covered medication list. (These are published lists as of 11/1/22):

Anthem Blue Cross

Blue Shield of CA

HealthNet

• • Click on Affordable Care Act Exchange Drug List (on/off exchange Individual and Small Group plans)

Kaiser

• • Use online search tool or open pdf of California Marketplace Formulary

OSCAR

• • Open pdf for California – Individual for 2023 plan year

Sutter Health PLUS HMO

Western Health Advantage

• • Click on Prescription Drug Search

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Billing

When you enroll online, paying by credit card for the first month’s premium is recommended for a smoother enrollment. You’ll have options on how to pay future premiums. For future billing inquiries, requests or problems, you can reach the carriers at following phone numbers and email addresses (where applicable):

• Anthem Blue Cross – Member Services — 866-249-4844
• Blue Shield CA – Member Services — 888-256-3650 / customer.service@blueshieldca.com
• Health Net – Member Services — 800-839-2172
• Kaiser Permanente – Member Services — 800-464-4000
• Sutter Health Plus – Member Services — 855-315-5800
• Western Health Advantage – Member Services — 888-563-2250 / memberservices@westernhealth.com