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What is a Preferred Provider Organization (PPO) plan?

Although it is not required that you do so, when you use the insurance company’s network of preferred doctors and hospitals, a PPO plan will have lower costs. If you choose an out-of-network provider, the cost will be much higher. In-network healthcare providers have predetermined rates, usually nominal, for the provision of each service to the health insurance plan’s members. Consider the following example: Let’s assume that the out-of-network coverage rate is sixty percent. This means that the insurance company will pay sixty percent of what that service would have cost had you gone to an in-network provider. If you received $500 worth of services from an out-of-network provider and those same services were available from an in-network provider for $250, the insurance company will only pay sixty percent of $250, which is $150, leaving you responsible for the remaining $350. Another consideration is that not only may up-front payment be required, but the out-of-network provider will not submit your claim for reimbursement.

It is generally not required to pick a primary care physician which allows plan members to seek medical services from any doctor or specialist within the network. While one of the most popular qualities of PPO plans is the flexibility in choosing providers, it is essential to confirm that your preferred doctor or neighborhood hospital belongs to the network. Additionally, if you will be including children in your plan, preventive and well-child care benefits will be of special importance to you. An annual deductible typically must be met before the insurance company starts covering your medical bills. A co-payment may be required for certain services or it may be necessary for the plan member to cover a certain percentage, or coinsurance, of the total charges.

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