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
  • Highest
  • High deductible
  • 60% of care covered after deductible
  • Limited benefits before deductible is met
  • Moderate
  • 70% of care covered after deductible
  • Multiple cost sharing options available through Covered California*
  • Lower
  • No deductible
  • 80% of care covered
  • Lowest
  • No deductible
  • 90% of care covered
Might be right for you if you...
  • Need coverage at the lowest possible monthly cost
  • Seldom visit the doctor or take medications
  • Prefer to "pay as you use" care
  • Moderate user of health care and prefer lower out-of-pocket costs
  • Qualify for lower cost-sharing benefits through Covered California
 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.

The IFP 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 a PPO plan 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.

* We make efforts to ensure that our list of providers is current and accurate. However, because providers leave networks from time to time, this list is subject to change, and you are encouraged to check with the provider before using their services.

© California Physicians' Service DBA Blue Shield of California 1999-2024. 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.

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