A health insurance policy determines the types of medical services or benefits you are covered for, which doctors you can see, and what hospitals you can visit. Your plan also determines what you pay for care and services.

After purchasing a health plan, you can then visit a doctor or hospital in the Blue Shield of California network. A network is a group of doctors, hospitals, and healthcare providers that work with a health plan like Blue Shield. That means you only have to pay a certain amount for healthcare services instead of the full cost. By using in-network doctors and hospitals, you can keep your costs lower.

Health insurance is for preventive and event-based care – meaning you don’t have to wait until you’re sick to see a doctor. Preventive services like annual exams and flu shots are available to you at no additional cost.

Individual and family medical coverage plans are healthcare plans that cover individuals and families rather than employer groups or organizations. Medical plans can be HMO or PPO. Dental plans can also be PPO or HMO, but vision plans are not.

Individual health coverage

• Covers one person. The individual is responsible for meeting their deductible before their coinsurance kicks in and the plan starts paying for a portion of their healthcare costs.

Family health coverage

• Covers two or more people, such as a spouse or children under the age of 26. Family coverage has an individual deductible within the family deductible. Blue Shield will pay benefits for an individual member on the family plan once the member meets the individual deductible amount. Blue Shield will pay benefits for all covered family members once the family deductible is satisfied. The family deductible can be satisfied when two family members meet their individual deductibles, or when the combined deductible contributions of three or more members reaches the family deductible limit.

When choosing between an HMO (health maintenance organization) and a PPO (preferred provider organizatio) plan, consider things like cost, flexibility, and network size.

• HMO plans are usually more affordable than PPOs, with lower monthly premiums and out-of-pocket costs. An HMO plan has lower costs because you agree to use a particular network of providers.
• PPO plans typically have higher monthly premiums and higher out-of-pocket costs, but give you access to a larger network of doctors. PPO plans even cover some of the cost for most covered services received from non-network providers.

You can enroll in an individual or family plan during Covered California’s annual open enrollment period from November 1, 2024 through January 31, 2025. You can apply for a plan outside of open enrollment if you’ve had a qualifying life event such as losing coverage through your employer.