Do you have a good understanding of your current plan?
How does cost sharing work in my health plan?
Your health plan is a financial planning tool that allows you to manage your exposure to healthcare costs throughout the year. The plan you choose determines how much coverage you will receive and what your out-of-pocket responsibilities will be.
When you purchase a healthcare plan, your expenditures come in four forms:
Premium
The fixed monthly amount that you pay every month so that you are covered by a health insurance plan. This coverage entitles you to free preventative services and protects you from large unexpected medical costs.
Deductible
The amount you must pay out of pocket each year under some (but not all) plans before your plan coverage takes over. You pay 100% of your care costs until you spend your deductible amount. Deductibles help keep premiums lower for people who want the safety of an insurance plan but don’t go to the doctor very often.
Cost sharing
The amount you pay under your plan when you access care after having met your deductible. Cost sharing can come in the form of co-pays (fixed dollar amounts for specific items like an office visit or prescription) or coinsurance (a percentage of the cost of a procedure, surgery or hospital visit, etc.) In network coinsurance amounts are based on the allowable amounts Blue Shield has negotiated with network providers, not the total amount billed.
Out-of-pocket maximums
This is the maximum amount you will pay for health care services covered by your health plan in a given year. Your out of pocket maximum includes your deductible(s), copays and coinsurance. Once you hit this maximum in a given year, your health plan will pay 100% of covered benefits for the rest of the year.
PLEASE NOTE: PPO plans have separate deductibles, copays, coinsurance and out of pocket amounts for in network providers and out of network providers. Using network providers is generally more cost effective than not and some services are not covered when you go out of network.
How do the different plans impact my health care spending?
All health plans are described by “metal” levels under the Federal Affordable Care Act to help consumers easily identify how plans work. While you may be familiar with Olympic medal ranking, in the case of "metal" levels, Gold is not necessarily better than Bronze. These plans simply offer different methods of covering your care and managing your exposure to unplanned healthcare expenses.
The primary difference between the “metal” plans is whether you prefer to pay a higher monthly premium with lower out-of-pocket costs when you receive care, or a lower monthly premium with higher out-of-pocket costs when you receive care. Bronze plans offer the lowest monthly premiums but have the highest out-of-pocket costs when you need care. Platinum plans have the highest monthly premium but the lowest out-of-pocket costs for care. Silver and Gold plans offer a balance between monthly premium and out-of-pocket costs.
When considering which plan to choose, think about how many health care services you and your family expect to use in the coming year. Sometimes, if you go to the doctor often, have planned surgeries or chronic conditions to manage, paying a higher monthly premium may save you money in the long run by lowering your out-of-pocket costs.
| Bronze | Silver | Gold | Platinum | |
|---|---|---|---|---|
| Premiums | Lowest | Variable with cost sharing options | High | Highest |
| Out-of-pocket costs |
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| Might be right for you if you... |
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Visit the doctor often, take multiple medications, or have other consistent care needs | Have chronic conditions and/or anticipate needing surgery |
*Eligibility based on income
How does my plan affect my access to doctors and hospitals?
Every plan has an associated “network” of doctors, hospitals, laboratories, specialists, and urgent care facilities. This network defines where and with whom you can use your coverage. Blue Shield offers two networks to best fit your needs. Whether you purchase your plan through Blue Shield directly or through Covered California, the networks are the same.
Our PPO network is the largest state-wide network in California and offers you the ultimate flexibility in choosing physicians, hospitals, and care providers. This typically comes at a higher cost, but you might be surprised at how affordable our PPO plans are.
Our Trio HMO network is a carefully selected smaller network of providers that provide exceptional care at a significantly lower cost when you receive care within the network.
If you currently have a Trio HMO plan and you are happy with your care providers, then you are all set. If you anticipate needing specific specialists or facilities to meet your specific health needs in the coming year then the PPO might be the right choice for you and your family.
You can use our Find a Doctor tool to help identify what providers and facilities are in your network that may need to access in the coming year. Visit the help page for more info about this tool.
