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Home   >  Understanding Your Plan   >   Types of Plans   >   Prescriptions & Exclusions   >   Limitations & Exclusions

Health insurance is not very straight forward and easy to understand.  When you are choosing a plan, make sure you do the right research, the first time.

What does it all mean?

There are many types of insurance plans out there.  When doing your research, make sure you understand these important elements:

Deductibles and Out-Of-Pocket Maximums
  • The deductible is the amount that must be met before the insurance company starts to cover expenses.  For many routine visits like seeing a doctor, the deductible is waived.  Meaning, make sure you check and see when your deductible will apply. 
  • The out-of-pocket maximum is the most you will have to pay per year.  Once you meet this maximum, the plan covers 100% of all bills for the rest of the year.  This number resets every January so be careful. 

In-Network vs. Out-of-Network

  • Depending on the type of plan you select, your coverage for in vs. out-of-network will vary.  For instance, most HMOs do not provide coverage for out-of-network providers.  However, if you have a managed care plan, such as a PPO or POS, then you have more flexibility to use different doctors and hospitals depending on what you select. 


  • This is the amount you are obligated to pay for covered medical services after you have satisfied any co-payment or deductible requirements on your plan.  It is usually expressed as a percentage that varies from plan to plan.

Prescription Drugs

  • Not all plans cover drug benefits.  Additionally, there are different types of coverage such as generic, brand, and non-formulary.  Make sure you check out the prescription benefits and coverage amounts when looking at the different plans.

Emergency, Hospital and Outpatient Care

  • Hospital and Emergency Care:  Depending on which plan you choose, you might be responsible for a copayment or coinsurance for being admitted to the hospital or even an emergency room visit.  The plan you choose will let you know what the coverage is for these services and any potential copayment or coinsurance rates you will be responsible for.
  • Outpatient surgery is any surgical procedure where you do not need to stay overnight.  The plans will say how much coverage you have and what potentially you’re responsible for.      

Maternity Care Coverage

  • Many health plans do not cover maternity.  If you are expecting a family soon, please make sure you select a plan that has full maternity coverage.

Is that it?

Below are some of the other typical services covered by health insurance.

  • X-rays
  • Skilled Nursing Care
  • Physical Therapy
  • Lab Tests

To start researching the right plans for you, click here to get instant quotes of all the major carriers in California. 

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