A Basic Explanation
A PPO plan does not require you to select a primary care physician or get a referral to see a specialist. You can see any doctor or provider within your network. You can also see providers outside your network, but it will cost you more. These plans offer you some flexibility.
Expert Advice About PPO Plans
The first thing you’ll notice about a PPO is the network size. In general, there are more doctors, hospitals, specialists, and other providers in a PPO network than in an HMO or POS. This means you’ll have more providers to choose from when it’s time to get care.
The second thing to note is that you can get care from providers who aren’t in your network if you want. But out-of-network care will probably cost you more. If you choose an out-of-network doc, you’ll likely have to pay a higher deductible or higher coinsurance (or both).
A few dos and don’ts for PPOs
Don’t: Visit a provider (unless it’s an emergency) before confirming whether he or she is in your network.
Do: Call before you go so you know whether a doctor or facility is in-network or out-of-network.
Why: Coverage for in-network providers can be a lot more generous than out-of-network coverage. You don’t want to get surprised later. Know ahead of time whether your doc is in or out.
Don’t: Call a provider and ask: “Do you take [carrier name] insurance?”
Do: Call a provider and ask: “Do you take [plan name] from [carrier name]?”
Why: Your carrier has LOTS of plans. Some of those plans may include your doctor in the network. Some won’t. Be specific. Ask about your particular plan.
Don’t: Assume you’ll pay the same copay no matter which provider you see.
Do: Call ahead and ask.
Why: Copay amounts can vary for providers within your network. What you owe could be even higher if you see an out-of-network provider.
Don’t: Get an expensive procedure or test without calling your carrier first.
Do: Check to see whether preauthorization is required.
Why: Some procedures and tests (such as surgery, radiology tests, or hospitalization) have to be approved by the carrier beforehand. If you don’t get preauthorization, you may get stuck paying the full cost yourself. Play it safe. Call your carrier before any major procedure or test to be sure it’s covered, and get preauthorization if you need it.
Don’t: Assume PPO plans are the most expensive.
Do: Comparison shop your options.
Why: Lots of different factors go into the price of a plan. Network size is one — generally, larger networks have higher premiums. And while it’s true that PPOs often have larger networks than HMO and POS plans, it’s not always the case. Don’t short-change yourself by making assumptions about PPO cost relative to other plans. Check the details. And if you want help, contact a licensed broker for advice.
