YOUR FIRST AND LAST (HOPEFULLY) GUIDE TO CALIFORNIA HEALTH INSURANCE NETWORKS
Over the years, we’ve put together multiple articles on California network issues but it’s time.
It’s time for one, all encompassing guide with the California networks answers all laid out in one place.
EPO’s. HMO’s. PPO’s. Covered Ca networks. Blue Card.
You name it, we’re going to cover it.
Question is why?
More importantly, why should you take busy time out of your schedule to read it.
Because it directly translates into money. Potentially lots of money out of your pocket.
Health insurance is mandated now and there’s even tax credits available to absorb the cost.
Great. What good is a plan if no one accepts it. Not so great.
Let’s get to the bottom of how to compare the networks and choose the best one for YOU!
First, The Before And After ACA Law Network Changes
A PPO is a PPO? Right?
Wrong.
There are different networks available now since Jan 1st 2014 and a tremendous amount of frustration and confusion has resulted.
With the clients. At the doctor’s offices. At the carriers. Enough to go around.
Here’s the deal.
For most carriers, there are essentially two networks for each different type (PPO for example).
There are the old networks (which still exist) for company sponsored health plans and old “grandfathered” individual/family plans.
These networks are not available to new enrollees after Jan 1st of 2014 (so, now basicallly).
These are broader networks and we’ll get to why later.
There are also new ACA networks
ACA stands for Affordable Care Act but most doctor offices know “Covered California”
IMPORTANT: There is no difference in network between a plan purchased through Covered Ca and one purchased off-Exchange directly through the carrier
Put another way…there’s no way to get away from the new ACA networks.
That question comes up quite a bit.
Here’s the skinny.
The new ACA networks are about 2/3rds the size as the old networks (within a type…i.e. PPO).
There’s no way around that other than through employer sponsored health coverage so that may factor into your decision to keep Cobra or not.
You can always run your quote here:
Is Your Doctor In The New Network?
You can try the online directory by carrier here
There have been issues with the online directories so we recommend asking the doctor,
“What Covered California plan do you participate in?”.
Make sure to say “Covered California” even though we mean ACA since the doctors know that by now.
The replies may be confusing but were happy to find out for you. Just email us the doctor’s name and city to help@calhealth.net
Okay, so that’s the before and after question (very important).
What about the network types?
The Landscape For California Doctor Networks
There are three basic network types now in the market:
PPO, HMO, and EPO.
Each carrier will generally offer 1 or more in most counties (but not all). Most carriers will offer either an EPO or a PPO (but not both) in a given county.
So how do they differ?
Let’s look at each one in detail and give our 20 years experience take on them.
PPO – Preferred Provider Organization
The PPO network is generally the broadest available in a given area.
Here are some highlights of the PPO network:
- Larger than HMO network of doctors
- Does not require a primary care doctor or designated medical group
- Allow more flexibility in self-referral and location
- Pays best benefits in-network
- Limited benefits (very limited in fact) for out of network providers in a non-emergency
- May allow use of Blue Card providers out of State and access across State
UPDATE: The Blue Shield Individual Family PPO plans will not have access to Blue Card in 2019
Those are the highlights of the PPO. What does it really mean?
Well, the benefits are now standardized so a Silver plan is a Silver plan regardless of PPO or HMO.
There used to be benefit differences between PPO and HMO but that’s no longer the case since ACA.
In general, PPO plans are more expensive in a given area for a given aged person
PPO is essentially a giant group discount. On average this discount, also called the negotiated rate, will save you 30-60% off the full price for the medical service.
This discount is even more pronounced with hospital, labs, and facility based care.
We’ve seen claims where the gross rate was $20K and the negotiated rate was $3K!
The discount is still good for doctor. It’s much smaller for medication (but still run your RX through your insurance card).
Who Does The PPO Work For?
PPO’s are generally best suited for:
people who want the broadest access to doctors and hospitals.
People who live close to the California border with another State
People who want access to out of State providers or travel/work elsewhere
Less cost restricted in terms of monthly premium
In most cases, the PPO is the premier choice for networks. There’s rarely a benefit (aside from premium savings) to the HMO or EPO…which we’ll explain next.
What Is The EPO Or Exclusive Provider Organization?
The EPO had fallen out of fashion until the Affordable Care Act but it’s back with a vengeance.
The two Blues (Anthem Blue Cross and Blue Shield of California) have basically offered an EPO in half of the State.
So why the big come back for EPO’s?
The EPO functions very much like the PPO with one exception.
There is no out of network benefits except for a true Emergency with the EPO
Does this really matter?
In our experience, the PPO and EPO have behaved very similarly.
In a true emergency, they are going to take you wherever is closest to get you patched up.
So we’re really talking about non-emergency or elective services?
What’s a real example of the differences between the EPO and PPO?
Let’s say we have a office visit with a small procedure.
The office visit full cost is $120 and the procedure (same provider) is $200. The provider is out of network.
With the PPO plan and a Silver plan, you might pay $90 for office copay and $150 for the lab. That’s roughly $240. Again, in-network, you would have copays but we’re paying quite a bit more since provider is in network.
With the EPO, you would pay the full cost. $320.
Here’s the real take away.
DON’T USE OUT OF NETWORK PROVIDERS FOR NON-EMERGENCY
Or be ready to pay a lot more if you do.
WIth an EPO you have access to the full PPO network in your area and self-referrals work the same way.
Very similar in day to day interaction as long as you STAY in-network.
From our experience, the PPO plans aren’t great out of network anyway. Avoid out of network or be prepared to pay.
This bring us a good point for both EPO and PPO:
Always check with providers before services to make sure they are in-network with YOUR plan (remember, different PPO confusion above).
Also, check the ancillary providers as well. For example, if you have a surgery planned, check the facility (very important), anesthesiologist, etc.
No surprises. That’s our motto!
EPO And Out Of State Or Cross-State Providers
One other key point. Since ACA came into effect, the EPO will likely not allow you access to providers in other States via the Blue Card network or even across the State.
UPDATE: The Blue Shield Individual Family PPO plans will not have access to Blue Card in 2019
Always check first but for some people, this might make a huge different (living on California/Nevada border for example).
Okay, recap. EPO is very similar to PPO except for no out of network.
What about the HMO?
HMO Or Health Maintenance Organization Makes A Comeback
Net net…the HMO was and is an answer to high insurance premium.
The HMO basically gives the doctor a stake in health care costs for patients he/she sees.
The insurer transfer some of the financial risk to the medical group/primary care doctor in managing health care.
What does that really mean for you, the member?
Basic highlights of the HMO network:
- HMO plans generally require a primary care physician (PCP) or medical group
- PCP or medical group is within a radius (i.e. 45 miles) of member’s residence
- HMO’s tend to less expensive than PPO’s or EPO’s
- HMO’s “manage” care more in terms of referrals and course of treatment
- The number of doctors/facilities is smaller in HMO networks
- You can generally change PCP’s only if you’re not in a course of treatment
Alright, so we’re trading off size of network and control for monthly premium savings.
That’s the real trade-off!
That trade off works for many people especially people that do not access much health care.
HMO’s work best in more populous areas (cities, densely populated suburbs, etc)
There are enough members to make this structure work.
Again, the benefits are now standardized. A Gold plan is a Gold plan regardless of carrier or network.
HMO’s and Covered California
HMO’s had disappeared from the individual/family California market until Covered Ca came on the scene. They’re now pretty prevalent in most big areas.
In some areas, the pricing for HMO’s can be much lower (such as Los Angeles county). Low enough to really be a factor in the decision.
Breadth Of Doctors In Each Network
On average, the size of networks relative to each other follows:
pre-Covered Ca PPO – about 80% of California doctors
Covered Ca PPO – about 2/3rds the size of pre-Covered Ca; approx 50% of Ca doctors
EPO – same list but constrained to area and in California
HMO – about 2/3rds the size of PPO network
Future Of Covered California Networks
The carriers (under pressure from legislatures) have steadily added providers to the new networks.
They will always be smaller since coverage is now guaranteed issue and there’s so much political pressure on keeping costs down.
Why did the network shrink in the first place?
The ACA law created both a ceiling and a floor. The ceiling is political pressure for keep rates lower. The floor is the mandated benefits that must be included in each plan.
The doctors (and the drug formulary) were the give. The only place for price pressure to be applied.
The reimbursement to doctors is lower on the new plans. That’s really what drives everything above.
Fewer doctors are willing to accept lower pay (understandably) and therefore, the networks shrink.
We’ll watch how this proceeds but we expect the networks to remain smaller.
When Can You Change Networks And Plans?
Barring a big life change, we have to wait to Open Enrollment of each year (generally Nov 15th – Feb 15th) to change plans and networks.
IMPORTANT: If you were given incorrect information on network participation, we may be able to change outside of open enrollment
You can access the online application here:
Help With The Network And Plan Decision
We have helped 1000’s of Californians find the best priced plan that matches their doctor/hospital needs.
Call us at 800-320-6269. Our services are Free!
This network selection is only one aspect of the decision but it’s never been more important than now.
Your Calhealth Advantage
Our online tools, free quotes and licensed agents are here to help you find a plan.

ON THE BLOG
Featured Articles
California Individual Vision Insurance
California Health Reform Subsidy
California Health Insurance Resource List
California Health Insurance Rate Increases
California Health Insurance Office Copay
California Health Insurance Maternity and Individual
California Health Insurance Individual Versus Cobra
California Health Insurance Individual Underwriting
California Health Insurance Group Value Dental Vision
California Health Insurance Group Kaiser
California Health Insurance Definitions
California Health Insurance Coverage Rescission
California Health Insurance Continuing Education
California Health Care Rights
California Blue Shield Vital Shield
Best California Health Insurance Plan
Affordable California Health Insurance
Understand Senior California Health Insurance
Covered California for Small Business
Individual California Health Insurance If Declined
Individual California Health Insurance Application Questionnaire
Health Net California Application Center
GURU Which Plan Should I Go With
GURU Subsidy If Offered Group Coverage
Do HSA Funds Roll Over
Compare and Contrast Alieracare Health Sharing Plan Benefits
California Vision Insurance Group
California Individual Dental Insurance
California HSA Plans and Health Reform
California Health Insurance Simplified
California Health Insurance Hospital Plans
California Health Insurance College Plan
California Health Insurance Cancel Individual Group Insurance
California Health Exchange Platinum Plan
California Health Exchange and Non Exchange Plans
Bronze California Health Plan
Covered California Open Enrollment How To
Covered California Open Enrollment
Covered California Early Pre Enroll
Small Business Tax Credits Covered California
GURU What If I Miss Open Enrollment Period
Free Assistance Covered California Enrollment
Covered California Enrollment After Open Enrollment
Comparing Deductible and Out of Pocket
California PCIP Health Insurance
California Medi-cal
California Health Insurance Group How to Choose
Avoid Bad Health Insurance Plan
Anthem Blue Cross California Application Center
How to Quote United Health National Restaurant Association
Hold On to Grandfathered Health Plans
Health Insurance for Engineering Firms
GURU What Income Period Do They Look At
Carriers
California Health Subsidy Calculator
California Health Reform Penalty
California Health Insurance Group Guaranteed Issue
Are Health Care Sharing Ministry Plans Worth It
Travel Medical Insurance
Term Life Insurance in California
Health Reform Rebates California Health Insurance
GURU Do I Use Business or Personal Gross Income
Guide Continuation of Coverage
Federal Poverty Level and California Health Insurance
California Individual Family Delta Dental
California Health Insurance Exchange
California Health Insurance Discount Plans
California Health Insurance Coinsurance
California Health Insurance Agencies
California Family Health Insurance
Obamacare Health Insurance for Gig Economy
Complaints California Health Plan
California Health Insurance Copays
Anthem Blue Cross Covered California Plans Rates Networks
Short Term Health Insurance
Short Term Insurance
Kaiser Covered California Rates Plans
California Health Insurance Individual Split Policy
Blue Shield of California
HSA Versus PPO Health Plans California
GURU What Effective Date Can I Pick
California Individual Family VSP Vision
California HSA HRA Health Insurance
California Health Insurance Dental Networks
California Health Insurance Concept
Pros and Cons of Health Sharing Plans Like Alieracare
Health Sharing Plans for Short Term Health in California
Embedded Deductibles in California Health Plans
United Health Group Rates Save Employers
Sharp Health in Covered California Reviews Plans Rates
Senior Supplement Best Value
California Health Insurance Negotiated Rates
AlieraCare CarePlus Advantage Catastrophic Health Sharing Plan Review Quote Comparison
Kaiser Through Covered California
TrumpCare HSA and Obamacare Covered California
Guide High Risk Pools
Common Questions Pre-existing and Options
California Restaurant Association United Health Plan
California Health Insurance Payment Options
California Group Health Insurance Eligibility
Current Individual HSA Health Insurance Options
Critical Illness Insurance Review Rates Plans
California Special Enrollment Periods SEP
California Health Insurance Life Time Max
California Health Insurance Claims Processing
Understand Group California Health Insurance
Student Health Insurance California
GURU Whats Difference Between In Out Exchange Plans
Are Health Sharing Plan Payments Deductible
Small Business Penalty Paying Individual Plans
Small Business Penalty Paying Individual Plans
California Health Insurance Primary Care Physician
Moving to California Covered California
California Small Business
California Health Insurance Sick Rates Change
Aetna Leaves California Individual Health Market
Covered California Tax Penalty
What is Best Health Sharing Ministry Plan
United Health Insurance National Restaurant Association Employees
Pacificare of California
La Care Health Plan Review Rates Networks
Covered California Compare Bronze Silver Plans
California Medicare Supplement Center
Basic PPO Blue Cross California
Critical Illness Insurance California
California Small Group RAF
Health Net In Covered California Reviews Rates Plans
California Insurance and Alternative Health Care
What Is Health Sharing Ministry And Plan
Covered California Versus Short Term Health Insurance
California Health Emergency Urgent Care
Smart Sense Blue Cross California
Kaiser Short Term Health Insurance
California On Exchange Application Terms Conditions
Guide Group Health Insurance
Free Assistance Covered California Enrollment
By Major Insurance Company
Blue Shield California Plans Rates Reviews
California Health Insurance Group New Company
Covered California Tax Credit
Health Insurance by State
California Health Insurance Out of Network
Anthem Blue Cross Leaving California Market 2018
Losing Health Insurance After Divorce
Cobra
California Health Insurance Max Out Of Pocket
United Health versus Anthem Blue Cross California
Short Term Health Insurance Between Jobs
Cheap California Health Insurance
California Health Insurance Group Size
California Health Insurance Broker Agent
Anthem Blue Cross Covered California
California Health Insurance Group Premium Only Plan POP
California Health Insurance Deductibles
Alternative to Obamacare Health Insurance
Health Sharing Versus Covered California
Current Catastrophic Health Insurance Options
California Health Insurance Rates Based On
Covered California Open Enrollment Changes
California Health Carrier Comparison
Missed Health Insurance Open Enrollment Deadline
What are Medicare Excess Charges
How to Apply for Aliera Care Health Sharing Plans
Medicare Supplement versus Medicare Advantage Comparison
Major Medical California Insurance
Immediate Health Insurance In California
Individual Health Insurance Between States
How to Pay Covered California Premium
Already Pregnant California Health Insurance
Health Insurance for High Earners California
Obamacare Health Insurance Versus Health Sharing Comparison
California On Exchange Application
Is Western Health Advantage PPO or HMO
Health Insurance Between Retirement And Medicare
California Retirement Health Insurance Options
California Health Insurance Group 1099
California Health Insurance Blue Card
California Health Insurance Acupuncture
Are Health Sharing Plans Like Alieracare Tax Deductible
Guide California Health Doctor Network
Health Savings Account
GURU What If I Move To California
Blue Cross Blue Shield Short Term Health Insurance
Calcobra Extension
Oscar California Health Insurance Review Rates Plans
Losing Health Insurance at Age 26
California PPO POS Health Insurance
California Health Reform 400 Poverty Level
Covered California Login Issues
California Health Insurance High Deductible Plan
GURU Medi Cal for Children
California Health Pre Existing Condition
Obamacare Income Guidelines in California
How to Designate Covered California Agent
How to Quote AlieraCare for Short Term Coverage
California Health Insurance Full Time Student
Do Health Insurance Plans Cover CBD
Catastrophic Health Insurance California
California Health Insurance Out Of State Employees
Covered California Marketplace Tax Credit
Health Insurance For Larger Family Of 4 5 6 Or More
Common Questions Individual Contract
Can You Have HSA Account With Health Sharing Plans
Blue Cross Senior Smart Choice
GURU What If My Income Changes
California Health Insurance Carrier Comparison
Self Employed Health Insurance California
Health Insurance for 1-2-3 Months
How to Apply for Covered California
Kaiser Versus Western Health Advantage Comparison
California Health Insurance Chiropractic
Covered California Versus Cobra Comparison
California Los Angeles Medi Medi Anthem Mediblue Health Plan
How to Quote Aliera Care Health Sharing Rates
California Health Insurance Dependent Children
GURU Tax Filing Status and Covered California
California Health Insurance HMO Versus PPO
GURU Difference Between EPO And PPO
California Health Insurance Group Part Time
Comparing Covered California Plans
Covered California Self Employment Income
Health Net Versus Anthem Blue Cross Comparison
Common Questions Time to Process Application
GURU What Type Of Income
Kaiser Versus Sharp Health Plan Review Comparison
How To Pick Best Covered California Health Plan
Do HSA Funds Roll Over
Anthem Blue Cross Versus United Health Comparison
Kaiser Versus PPO
Aliera Care Health Sharing Plan Review Rates Plans
Health Care Sharing Ministry Comparison Review
Emergency Health Insurance California
Secular Non Religious Health Sharing Plan
Blue Shield California Versus United Health Comparison
Kaiser Versus Health Net Comparison Reviews
Health Net Versus Blue Shield California
Blue Shield Versus Anthem Blue Cross California
Blue Shield California Individual Rate Increase
Does A Company Have To Offer Health Insurance California
Kaiser Versus United Health Comparison Reviews
Kaiser Versus Anthem California
Blue Shield California Versus Kaiser Comparison Review
Blue Shield California Individual Rate Increase
Holiday
California Health Insurance Law
Blue Cross Smart Sense Individual
Blue Cross May Focal Renewal Group
Blue Cross Group Rates
Blue Cross California Individual Rate Increase
Blue Cross California Individual Rate Increase
Blue Cross Anthem Name Change
SCHIP Status
Immunizations
HSA Guideline Update
Blue Shield HIPAA Approach
Blue Cross Urgent Care Network
Blue Cross Small Group Rate Increase
Blue Cross Rate Increase Individual
Blue Cross Rate Increase Client
Blue Cross New Consumer Driven Plan
Blue Cross Healthy Living
Antibiotic Power
Holiday
California Mental Health Parity Bill
California Mental Health Parity
Blue Shield Rate Increase Individual
Blue Shield of California
Blue Cross Transfer To Colorado Nevada
Blue Cross Lawsuit
Blue Cross Billing Fee
Blue Shield New Individual Plans
Blue Cross Core 5000
Two Decades Of Helping Californians Find Affordable Health Insurance
Kaiser Versus Blue Shield Of California
See All Reviews on the Blog
See All Reviews on the Blog
- Over 500,000 Quotes
- 10’s of 1000’s Enrolled
- Guaranteed Best Rates
- Referenced for finding affordable
- California Health Inurance

20 years of experience in the California health insurance market has taught us one thing… Competent and experienced guidance is INVALUABLE
We are licensed Covered Ca agents with in-depth knowledge of their plans, process, and tax credits.
This website is owned and operated by Goodacre Insurance Services, which is solely responsible for its content. This site is not maintained by or associated with Covered California, and Covered California bears no responsibility for its content. The email address and phone numbers that appear throughout the site belong to Goodacre Insurance Services, and cannot be used to contact Covered California.