PPO health insurance is a group program providing medical services through a network of physicians, hospitals, clinics and other health care practitioners. A PPO, or preferred provider organization, gives members flexibility in selecting doctors and other medical practitioners to provide covered services.
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What are the benefits of a PPO plan?
Unlike traditional HMO programs, a PPO plan allows members to seek medical attention from any doctor or practitioner without a referral or other authorization. The trade-off is that PPO subscribers are obligated to pay a portion of the doctor’s fees for each visit. They must also pay a portion of other covered services such as an emergency room visit or a hospital stay.
These proportionate fees are called co-payments or co-pays. They are usually small, ranging from five dollars to fifty dollars per visit, but can be more. Co-pay fees are dependent on the nature of the medical service provided and the specific terms of the enrollee’s PPO program contract.
What are deductibles?
Deductibles are established minimum and maximum amounts that a subscriber can be expected to contribute towards their own medical expenses during a policy year. These can range from a few hundred dollars to a thousand or more depending on the terms of the policy.
What are the benefits of a high deductible policy?
If you are willing to accept a higher out-of-pocket deductible expense during the year, then you can look forward to lower premiums by requesting a high deductible type policy. Persons who seldom seek or need medical attention will benefit most from this option.
Consumers should be cautious about making this choice, because a few necessary doctor visits that have to be paid in full by the insured, or a brief hospital stay, can quickly erase any monetary benefits gained from the reduced monthly premiums.
High deductible limits, most often range from twelve hundred to fifteen hundred dollars, for a year, but they can be much more. Once a policy deductible limit has been reached, normal co-payments apply once again, continuing through the balance of the insured’s policy year.
Are there other health insurance options?
Yes! The other common health insurance choice is an HMO, or health maintenance organization.
An HMO coordinates all medical services for its members. Like PPO groups, HMOs feature provider networks under contract to each HMO group. This type of comprehensive service is also known as managed care.
From the HMO network of service providers, each member must select his or her own primary care physician, (PCP). This is an important selection since all non-emergency medical services must be approved and/or referred by a member’s PCP. A PCP must be consulted before any lab work or tests are done, or any medical specialist is consulted.
PCPs are generally familiar with other practitioners in their network and can offer their patients referral choices based on their experience and the subscriber’s specific needs. Primary care physicians may be general practitioners or specialists. For example, a woman may select a gynecologist as her PCP, while children would normally see a pediatrician.
How much do I have to pay, out-of-pocket, for office visits or other medical services?
The major benefit of an HMO program is that 100% of all eligible services are usually covered. There are no co-payments or deductible expenses to worry about.
What if I want to see a doctor who isn’t part of the network?
On the other hand, the HMO plan won’t pay for visits to a doctor who is not a part of its own network. Services by outside providers are generally not covered at all.
What is a POS plan?
POS is a “point of service” program that is offered as an option by some health insurance carriers. This program seeks to combine some of the benefits of both the HMO and PPO programs. For more information, please contact health insurance providers in your area.
Many options for health coverage will vary from state to state and region to region. It is a good idea to investigate all the companies in your area, comparing rates and benefits before making a final selection.
Where can I join a PPO group?
First, check with your employer to see if a PPO group is an insurance benefit option. If not, you can find information for most insurance providers and their products on line.
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