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Why Do I Need Medical Coverage?

Health insurance is now the law. The Affordable Care Act commonly referred to as ACA or Obamacare, mandates that all citizens carry some type of medical care coverage. In addition, medical costs are soaring, and don’t show signs of slowing down. Who pays your bills when you have an accident or illness? People purchase health insurance for the same reasons someone would buy any other kind of insurance product, to protect yourself financially. With health insurance, you can protect your family in case you need care that can be very expensive. No one can predict what medical bills you might incur. In good years, your out of pocket expenses may be insignificant. But in the event you become sick, your bills can become overwhelming. If you do carry health insurance, then many of your bills would be covered by a third-party payer, and not by you. Besides an insurance company, a third-party payer can also be your employer.


Health Insurance Fullerton

Americas Health Care system is changing rapidly. Today, most Americans have health insurance through enrollment in a health maintenance organizations (HMOs), preferred provider organizations (PPOs), or point-of-service (POS) plan.

Since it is now the law to carry health insurance, there are many resources available for those who need financial assistance in paying for it. If you are a California resident and believe you qualify for a subsidy you can the Covered California website:

Types of Insurance

Fee-for-Service (Indemnity Plan)

Fee-for-Service is the most traditional kind of health insurance plan. The carrier pays the fees for any services provided to the individual that is covered by the policy. These plans offer the broadest set of choices for doctors and hospitals. An insured individual is allowed to choose and change doctors at any time. You can also visit a broad range of hospitals across the country.

With a fee-for-service plan, an insured only has to pay for part of the doctor and hospital bill. The following is what you would pay:

  • The premium, which is a monthly fee.
  • What is covered by my health plan? Does the plan cover prescription medication, out-of-hospital care, or in home care? What are the limits on the number of days and cost that the company will reimburse for these services? Plans can vary, but the best ones cover a broad range of services.
  • Do you currently have a medical condition you are being treated for that may not be covered under your new plan? Is there a waiting period or any limitations involved in the coverage?
  • What is my deductible? You can often lower your monthly premium by buying a plan with a higher yearly deductible amount.
  • What is the rate for coinsurance? What percent of your bills will you have to pay for allowable services?
  • What is the maximum out of pocket you would pay per year? How much would it cost you directly before the insurance company would pay everything else?
  • Is there a maximum cap that the insurer will pay in a lifetime? This is important to know if you or someone in your family has an illness that requires expensive treatments.
What Is a "Customary" Fee?

Most insurance plans will only pay for what they consider to be reasonable and customary fees for a particular service. If your doctor is charging $1,000 for a hernia repair, where most other doctors in your area are only charging $600, you will be billed for the $400 difference. This amount is in addition to the deductible and coinsurance you would be responsible for paying.

Questions to Ask About Fee-for-Service (Indemnity) Insurance
  • What will my monthly premium be? What is my maximum cost for the year? Rates are varied based on individual or family plans.
  • What is covered by my health plan? Does the plan cover prescription medication, out-of-hospital care, or in home care? What are the limits on the number of days and cost that the company will reimburse for these services? Plans can vary, but the best ones cover a broad range of services.
  • Do you currently have a medical condition you are being treated for that may not be covered under your new plan? Is there a waiting period or any limitations involved in the coverage?
  • What is my deductible? You can often lower your monthly premium by buying a plan with a higher yearly deductible amount.
  • What is the rate for coinsurance? What percent of your bills will you have to pay for allowable services?
  • What is the maximum out of pocket you would pay per year? How much would it cost you directly before the insurance company would pay everything else?
  • Is there a maximum cap that the insurer will pay in a lifetime? The cap is an amount after which the insurance company will no longer pay above. This is important to know if you or someone in your family has an illness that requires expensive treatments.
Health Maintenance Organizations (HMOs)

Health Maintenance Organizations are plans which are prepaid. As a member of an HMO, you pay a monthly premium for your chosen plan and in exchange, the HMO provides comprehensive care for you and your family. This care includes doctors' visits, hospital stays, emergency care, surgery, lab tests, x-rays, and therapy.

This care is arranged for by the HMO either directly in its own group network, and/or through doctors and other health care professionals whom they contract with. Usually, your choices are limited to doctors and hospitals that have agreements with the HMO to provide care. However, exceptions are made in the event of an emergency or when medically necessary. You may have to pay a small co-payment for each office visit, such as $5 for a doctor's visit or $25 for hospital emergency room treatment. Your total medical costs in an HMO will likely be lower and more predictable than with fee-for-service insurance.

HMOs receive a fixed fee for your covered medical care, therefore it is in their interest to make sure you get basic and preventative care before they become serious problems. HMOs typically provide preventive care, such as office visits, immunizations, well-baby checkups, mammograms, and physicals. Because HMOs vary in the range of services covered, it is important to compare available plans. Some services, such as outpatient mental health care, often are provided only on a limited basis.

It is a good idea to talk to people you know who are enrolled before choosing an HMO. It may be beneficial to ask their opinion on the services and care given.

Questions to Ask About an HMO
  • How many doctors are there to choose from? Is there a list of contract physicians or available staff of a group practice to select from? Which doctors are accepting new patients? Is it hard to change doctors if you decide you want someone else? How are referrals handled to see a specialist?
  • Is it easy to get appointments? How far in advance must routine visits be scheduled? What arrangements does the HMO have for handling emergency care?
  • Are the services I want offered by the HMO? What services are provided for preventative care? Are there limits on medical tests, surgery, mental health care, home care, or other support offered? What if you need a special service not provided by the HMO?
  • What is the service area of the HMO? Where are the facilities that serve HMO members located in your community? How convenient are the doctors, hospitals, and emergency care centers to your home and workplace that make up the HMO network? What happens if you or a family member need medical treatment and are out of town?
  • What will the cost of the HMO plan be? What is the yearly total for monthly fees? In addition, will there be copayments for office visits, emergency care, prescribed drugs, or other services? How much?
Preferred Provider Organizations (PPOs)

The preferred provider organization is a combination of an HMO and traditional fee-for-service, but provides more flexibility. Like an HMO, there is a network of doctors and hospitals that you may choose from. When you use those providers from within this group (sometimes called "preferred" providers, other times called "network" providers), most of your medical bills are covered. However, unlike HMOs, you can visit a specialist without a referral from your primary physician. There is usually a small copayment for each visit. In addition, you may have to pay a deductible and coinsurance for some services.

PPOs do not require you to choose a primary care doctor to monitor your health care. Also, most PPOs cover preventive care. This usually includes visits to the doctor, well-baby care, immunizations, and mammograms.

In a PPO, you may use doctors who are not part of the plan and still receive some coverage. In these instances, you may be responsible to pay a larger portion of the bill yourself (as well as fill out the claims forms). Some people like this option because even if their preferred doctor is not part of the network, it means they wouldn't have to change doctors to join a PPO.

Questions to Ask About a PPO
  • Do I have my choice of doctors to choose from? How do I know which doctors participate through the PPO network? Are they located near me? Are they accepting new patients? Can I get referrals to specialists?
  • Which hospitals are available through the PPO? Where is the nearest hospital in the PPO network to me? Is there emergency care available in the PPO network?
  • What kinds of services are covered in a PPO plan? Are preventive services also offered? Are there limits on certain services such as medical tests, out-of-hospital care, mental health care, prescription drugs?
  • How much will a PPO plan cost? How much will the premium cost? Are there per-visit costs for seeing PPO doctors or other co-payments for services? Can I use doctors out of network? What is the cost difference between using those in network and those out of network? Is there a difference in deductible and coinsurance rate for getting care outside of the PPO? What is the maximum out of pocket cost?

Where Do People Get Medical Coverage?

Group Plans

Health Insurance Fullerton

Most people obtain their coverage through their jobs or are covered by a family member who has insurance at work. This is called group insurance. This is generally the least expensive plan. In some cases, the employer will pay part or all of this cost.

Some employers offer only one type of plan. Others offer choices: a fee-for-service plan, a health maintenance organization (HMO), or a preferred provider organization (PPO), these are some examples. Employers with more than 25 employees are required by Federal law to offer employees the choice to enroll in an HMO.

You can get a group health quote here.

What if your family member leaves the job? Will you lose your employer- supported group coverage? It might be possible to keep the same policy, but you will have to pay for it out of pocket. This will definitely cost you much more than group coverage for the same, or less, protection. There is a Federal law that makes it possible for most individuals to continue their employer provided group plan for a period of time. The program is called COBRA. COBRA stands for, Consolidated Omnibus Budget Reconciliation Act of 1985, the law states that if you worked for a company of 20 or more people and are laid off or leave, you are eligible to continue coverage for at minimum 18 months. While you will be charged a higher premium once on COBRA, than what you were paying before, it will most likely be cheaper than obtaining comparable coverage on your own.

You also are able to acquire coverage under COBRA if your prior coverage was provided through your spouse and you are now widowed or divorced. Many students take advantage of COBRA once they graduate by remaining covered for up to 18 months if they were previously covered by their parent’s policy. However, once the individual finds a job that offers health insurance then they would no longer be covered by COBRA.

Health insurance is not offered by all employers. It’s possible that this might be the case with your current employer; this can be especially true if you work for a small business or hold a part-time job. If your current job does not provide you a medical plan option, you may be able to obtain group insurance through a membership organization such as a labor union, professional association, other organization. Many of these organizations provide plans to their members at significantly reduced costs compared to individual plans.

Individual Plans

If your current job does not offer a group plan, or if the offered plan is limited in scope and coverage, you can buy a supplemental policy. You can choose either HMO or PPO coverage. Each choice has its advantages so you should compare the options and carefully decide which plan and company fits your needs best.

You can get an individual health quote here.

Before purchasing any health care policy, make sure you understand what it will and won’t pay for. To discover more about an individual plan, you can call the insurance company, HMOs, and PPOs in your community, or speak to your Williams Health Insurance Agent Fullerton CA.

Below are some tips when shopping for your individual insurance plan:

  • Shop carefully. As covered above, policies differ greatly in both coverage and cost. You can contact the different companies, or more efficiently ask your Williams Insurance agent to show you the different policy options available from several different carriers.
  • Make sure that policy you choose protects you from potentially large medical costs.
  • Always read the policy and ask if you don’t understand. An agent can help guide you through the policy.
  • It’s important to check and see that the policy states the date that the policy begins providing payment. Many polices have what’s known as a waiting period. This is what’s known as a “time deductible”. It holds back coverage for set number days.
  • All good policies have a "free look" clause. This provides you at least 10 days to review your policy after you have received it. If for any reason you decide the policy is not for you, you are allowed to return it and have any paid premium refunded.
  • Always be cautious of single disease policies. These police offer protection for only one illness, such as cancer. If you currently carry health insurance, it is likely that your regular plan already provides all the coverage you would need.
  • Medicare

Medicare is the federally provided program for the following groups:

  • All individuals 65 or older
  • Individuals under the age of 65 with certain disabilities
  • All individuals regardless of age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)
  • The best resource for potential Medicare recipients is to contact a local independent Medicare Agent. Williams Insurance has professional independent Medicare Agents Fullerton CA with over 30 years of experience. We are here to answer all your questions with no hold times.
  • The government also provides handbooks for those who wish to read up themselves on Medicare. The Medicare Handbook - Medicare & You, as well as Your Medicare Benefits, is available for free through You also may contact your local Social Security office for the information.

Glossary of Terms

Calendar Year Medical Deductible

Deductibles for Participating and Non-Participating Providers accrue separately.

Calendar Year Out-of-Pocket Maximum

Any calendar year medical deductible and any calendar year pharmacy deductible accrue to the calendar year out-of-pocket maximum. Copayments or coinsurance for covered services from participating providers accrues to both the participating and non-participating provider calendar year out-of-pocket maximum amounts.


The Consolidated Omnibus Budget Reconciliation Act, also called COBRA, will give employees the opportunity to continue coverage for 18 months after employment is terminated. You may qualify for a longer term under certain circumstances. You will pay a premium for this coverage.


Coinsurance is the percentage you pay for care after you've paid your deductible. If your carrier was responsible for $200 and your coinsurance is 20% then you would owe $40.


A fixed fee that a company requires the patient to pay for certain covered medical expenses, such as office visits and services. Co-payments may also apply to prescription drugs.


The amount of money you must pay for care before your carrier pays out.


A service within a policy that rejects coverage for certain benefits, disorders or where you can get treatment.


A payment model for health care where the provider is paid separately for each service performed.

Health Maintenance Organization (HMO)

An HMO is an organization that works with providers they contract with to offer coverage. You pay a monthly premium and the HMO covers your doctor's, hospital labs, annual physicals, emergency room, surgery, preventive care, and other benefits covered by the plan. You choose a primary care doctor who coordinates all of your care and makes referrals to any specialists you might need. If you choose an HMO, you agree to use the doctors, hospitals and clinics that participate in your plan's network.

Health Savings Accounts (HSA)

An HSA is a medical savings account available to those who pay taxes. The funds contributed to an account are used for medical expenses and are not taxable at the time you make your deposits.

Lifetime Limit

This limit refers to the maximum dollar amount that a plan approves to pay as part of your benefit for covered services during your lifetime.

Managed Care

A system of health care in which patients accept the network of providers and visit only certain providers in which the cost of your care is supervised by the managing company. This would include HMO’s and PPO’s who use a provider network.


This federally sponsored program is hospital and medical insurance primarily for people age 65 and older and those with qualifying permanent disabilities.

Out-of-Pocket Maximum

After you pay out the amount stated in your policy as the Out-of-Pocket Maximum on your deductibles, copayments and coinsurance, your insurance will pay 100% of the costs of qualified benefits for the remaining of the benefit period (usually a year).

Point-of-Service (POS) Plan

A type of managed care plan which combines features of HMOs and PPOs. You make a decision if you want to go to a network provider and pay no deductible, of if you would prefer to pay a flat dollar copayment (say $20 for a physician visit), or you may choose an out-of-network provider and submit bills to be reimbursed after applying your deductible and possibly a coinsurance portion.


Pre-authorization is a cost control step whereby the insured or the insured’s provider must call the insurer prior to non-emergency services and request authorization for certain services.

Pre-existing Condition

A health condition that existed prior to your enrollment in a health plan. Under the Affordable Care Act, companies are not allowed to refuse enrollment due to medical conditions.

Preferred Provider Organization (PPO)

A network of doctors, hospitals and other health care providers who have agreed with an insurance company to offer health care at lower rates members of the plan. You may see any provider in the network without a referral. You may choose to go out of the network and pay a higher fee.


The amount you pay for insurance benefits.

Primary Care Physician

You choose a Primary Care Physician from the Network of Providers Directory who will manage your care and provide treatment as needed. A primary care physician refers you to specialists if necessary.


Any person, such as a physician, who participates in your medical treatment and participates in preventing illness or disability, or a facility such as a hospital, clinic, or lab, who render a service to members.

Third-Party Payer

Someone other than the patient or the health provider that reimburses and manages health care expenses. Third-party payers may include health insurance plans, governmental agencies such as Medicare, and also employers.

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