Preferred Provider Organizations (PPO'S)

Preferred Provider Organizations (PPO'S)

Preferred Provider Organizations (PPO'S)
The preferred provider organization is kind of like a “hybrid” between the traditional fee-for-service indemnity plan and an HMO. Like an HMO, there are a specific doctors and hospitals to choose from.  The main difference between a PPO and an HMO and what makes them preferable to many medical consumers is that unlike with an HMO, in a PPO you do not need to select a primary care doctor, nor do you need to seek a referral to see any type of specialist participating in the network. You also are not necessarily restricted to only using physicians in the network but you will typically pay more for “out of network” services.

Much like a traditional HMO when going to an “In Network” provider

with PPO there are no claim forms to fill out, you merely present your card- and as in a traditional HMO there may be a small co-payment for each visit. Some services in PPO may require a deductible and/or coinsurance.

PPO’s also generally will pay for preventive and wellness care such as visits to the doctor, well-baby care, immunizations, and mammograms.

The main difference between a PPO and an HMO that some see as an advantage is in a PPO can still use doctors who are not part of the plan and still receive some coverage. If you go “out of the network” you will pay a larger portion of the fee, and you likely will have to fill out claim forms, but people like the idea of the additional choice this gives them

Questions to Ask About a PPO:
Are there many doctors to choose from? Who are the doctors in the PPO network? Where are they located? Which ones are accepting new patients? How are referrals to specialists handled?

  • What hospitals are available through the PPO? Where is the nearest hospital in the PPO network? What arrangements does the PPO have for handling emergency care?

  • What services are covered? What preventive services are offered? Are there limits on medical tests, out-of-hospital care, mental health care, prescription drugs, or other services that are important to you?

  • What will the PPO plan cost? How much is the premium? Is there a per-visit cost for seeing PPO doctors or other types of co-payments for services? What is the difference in cost between using doctors in the PPO network and those outside it? What is the deductible and coinsurance rate for care outside of the PPO? Is there a limit to the maximum you would pay out of pocket?

Source material from: Checkup on Health Insurance Choices. AHCPR Publication No. 93-0018, December 1992. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/consumer/insuranc.htm.

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