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How does health insurance work?

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.

Coinsurance

A fixed percentage of the cost of your services that you’re responsible for. This is usually after you’ve met your deductible.

Copayment

A fixed amount you pay for benefits such as doctor’s visits or any wellness services. This is usually after you’ve met your deductible if your plan has one.

Deductible

The amount you pay each calendar year for most benefits before Blue Shield begins to pay. Some benefits, such as preventive care, are covered before you meet your deductible.

HMO

A health plan where you choose a primary care physician (PCP) who treats you regularly. This includes preventive visits and referrals to specialists. You’ll need to see only other doctors or specialists in your PCP’s medical group. There is no coverage for services received from doctors who are outside your PCP’s network.

Network

A group of providers – including hospitals, doctors, specialists and other healthcare providers – that have agreed with Blue Shield to provide benefits for a specified amount.

Out-of-pocket maximum

The most you are required to pay in combined deductible, copayment, and coinsurance amounts for all of the covered services each year.

PPO

A health plan in which members can choose to see any provider in the PPO provider network without a referral. Members also have the freedom to use non-network providers for most services if they are willing to pay a higher share of the cost.

Health coverage for more Californians

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MEMBER SUPPORT

Contact us
Forms
Confidential communications
Prior authorization list
Register for an account
Download the mobile app
Sharing your health information

SHOP PLANS

Individual & family plans
Medicare plans
Covered with an employer

OUR COMPANY

About Blue Shield of California
Trust Center
Blue Shield Foundation
News
Careers

LEGAL NOTICES

Nondiscrimination notice
Terms of use
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Cookie preferences
Regulatory notices

All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.