Preferred Provider Organizations
(PPOs)
The preferred provider organization is
a combination of traditional fee-for-service and an HMO. Like an HMO,
there are a limited number of doctors and hospitals to choose from.
When you use those providers (sometimes called "preferred"
providers, other times called "network" providers), most of
your medical bills are covered.
When you go to doctors in the PPO, you
present a card and do not have to fill out forms. Usually there is a
small copayment for each visit. For some services, you may have to pay
a deductible and coinsurance.
As with an HMO, a PPO requires that you
choose a primary care doctor to monitor your health care. Most PPOs
cover preventive care. This usually includes visits to the doctor, well-baby
care, immunizations, and mammograms.
In a PPO, you can use doctors who are not
part of the plan and still receive some coverage. At these times, you
will pay a larger portion of the bill yourself (and also fill out the
claims forms). Some people like this option because even if their doctor
is not a part of the network, it means they don't have to change doctors
to join a PPO.
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 copayments 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?
