What
is a preferred provider organization (PPO) plan, and how
does it work?
A
preferred provider organization (PPO) plan works for you
in two ways: through a panel or network of physicians and
other service providers (such as hospitals and labs), or
through providers you select that are not in the network.
Each time you or a covered family member needs care, you
choose whether to see an in-network or an out-of-network
provider.
Network providers are listed in your plan's provider directory.
When you use an in-network provider, also called "going
in-network," you generally receive a higher level of
benefits. Also, fees from in-network providers tend to be
lower, because the providers and the network have negotiated
to have the providers accept certain fees for certain services.
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With a PPO plan, do I name a primary care physician
(PCP)?
The
PPO plan does not require you to name a primary care physician
(PCP) or coordinate your care through a particular doctor.
However, you are free to choose a primary doctor, whether
or not that doctor participates in the network.
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What
are the advantages of obtaining my care from in-network
providers?
| There
are several advantages when you go in-network. Generally: |
| • |
You
may not need to pay a deductible, or your deductible
may be lower than it would be for out-of-network expenses. |
| • |
You
don't need to submit claim forms and wait to be reimbursed
by your plan. |
| • |
Your
in-network provider obtains any needed preauthorization
for you. |
| • |
You
generally receive a higher level of benefits because
participating providers (doctors, hospitals and other
health care facilities) have agreed to provide their
services at lower fees. |
| • |
Some
plans provide preventive care services in-network that
are not covered out-of-network. |
| • |
Some
plans limit covered services out-of-network, but offer
these services without a limit on the number of visits
when the care is provided in-network. |
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How
does the PPO plan work when I go out-of-network?
| Generally,
you may use any covered health care provider you choose.
However, your cost will generally be higher and you
have certain added responsibilities. For example: |
| • |
Each
year, you must pay part of your eligible out-of-network
expenses before the PPO plan begins to pay benefits.
This amount is called the deductible. |
| • |
After
you satisfy the deductible, the plan will reimburse
you for a percentage of your eligible expenses and you
will pay the balance. The percentage you pay is called
your coinsurance percentage. |
| • |
You
must get preauthorization for certain covered expenses
such as a hospital stay. If you don't get the required
preauthorization, the amount of benefits available will
be reduced or the expenses will not be covered at all.
This means your cost will be higher. |
| • |
You
must complete claim forms and file claims with your
health care company to receive payment of benefits.
|
| • |
The
plan will not cover any benefit reductions due to failure
to preauthorize certain treatments. |
| • |
The
plan will not cover any charges above the allowable
amount. |
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When do I need to file a claim form?
You
may not need to file a claim form when you see in-network
providers.
When you do need to file a claim form, as you need to do
in most cases when you go out-of-network, your doctor may
handle your expense in one of two ways. Most doctors require
you to pay the bill right away. In this case, get a receipt
and file it with a claim form to be reimbursed. If the expense
is covered, you will be reimbursed for part of the bill.
To file a claim, follow the instructions on the claim form.
If you have more than one health insurance plan and have
received an Explanation of Benefits (EOB) form from another
health care plan, be sure to include a copy with your claim.
Sometimes doctors are willing to wait for payment. In this
case, you or your doctor will file the receipt and completed
claim form with your health care company. The health care
company will pay the doctor for the part of your expense
the plan will cover. The doctor will then bill you for the
part the plan did not pay.
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What happens if I need specialty care that is not
available from in-network providers where I live?
You
may be referred to an out-of-network provider if you need
specialized care that your health care company determines
to be medically necessary and that is not available through
an in-network provider in your area. As long as you use
the provider you're referred to by your health care company
and follow your plans rules, you'll be covered for that
care at in-network benefit levels.
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What happens in an emergency?
In
a true emergency, get the care you need as quickly as you
can. If you are able, contact member services for your health
care company at the number on your ID card, even in an emergency.
However, even if you are unable to contact member services,
get the care you need. Even if you need to go out-of-network,
your plan will cover emergency care at in-network benefit
levels as long as you follow the plan rules.
Check to see how your plan defines a true emergency. Examples
typically include severe bleeding, chest pain, and unconsciousness.
Also check to see how soon after the onset of the emergency
you must notify your health care company in order to be
covered in-network.
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What happens if I need care while I'm traveling?
If
it's not an emergency and you need care while traveling,
call member services for your health care company at the
number on your ID card. Member services can refer you to
an in-network provider.
In a true emergency, get the care you need as quickly as
you can. If you are able, contact member services even in
an emergency, and your health care company can help you
decide where to go for care. However, even if you are unable
to contact member services, get the care you need. Even
if you need to go out-of-network, your plan will cover emergency
care at in-network benefit levels as long as you follow
the plan rules.
Check to see how your plan defines a true emergency. Examples
typically include severe bleeding, chest pain, and unconsciousness.
Also check to see how soon after the onset of the emergency
you must notify your health care company in order to be
covered in-network.
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What
is a deductible?
A
deductible may only apply, or may be higher, when you obtain
care out-of-network. A deductible is the part of eligible
expenses you must pay before the plan begins to pay a percentage
of your eligible expenses.
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Are
there expenses that don't count toward my deductible?
Yes.
Some of your expenses will not count toward your deductible.
For example, any penalty you may pay because you failed
to preauthorize treatment through your health care company
will not count. For out-of-network care, amounts your care
provider charges above the plans allowable amount for a
given service also will not count toward your deductible.
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What
is coinsurance?
Coinsurance
may only apply to out-of-network care. After you satisfy
the deductible, the plan will reimburse you for a percentage
of your eligible expenses for out-of-network care and you
will pay the balance. The percentage you pay is called your
coinsurance percentage.
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What is a co-payment?
A
co-payment generally applies to in-network care. When you
stay in-network, you pay only a fixed amount at the time
you receive services. That amount is called your co-payment.
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What
is preauthorization?
Preauthorization
is the process by which a health care company or preauthorization
company reviews the proposed treatment and tells you and
your doctor how benefits may be paid. If you receive care
out-of-network, you must obtain preauthorization for certain
covered expenses such as a hospital stay. Some plans also
require preauthorization for certain in-network services.
If you don't get the required preauthorization, your cost
will be higher because the benefits payable by the plan
will be reduced or the expenses will not be covered at all.
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What's the amount known as the "allowable amount,"
the "U&C amount" or the "R&C amount"?
The
terms "allowable amount," "U&C amount"
or "R&C amount" vary by plan but refer to
the same thing. The allowable, usual and customary or reasonable
and customary amount is the amount usually charged for a
given service by most providers in your area. This amount
is determined by your health care plan. If your doctor charges
you more than this amount, you will not only be responsible
for your deductible and coinsurance, but also for the entire
difference between the U&C amount and the amount your
provider charged. This concept only applies to out-of-network
care, because in-network providers have agreed to negotiated
fees that are by definition allowable amounts.
For example, suppose you receive a service for which the
"U&C amount" is $100 but your doctor charges
you $110. The health care company will multiply the percentage
the plan pays for that service by $100. So even if the service
were covered at 100%, you would pay the $10 difference ($110
charge minus $100 U&C).
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What are covered services?
Covered
services are services covered by the plan. No medical plan
covers everything. If you obtain services that are not covered
services, you pay the full cost for those services.
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What is an out-of-pocket maximum?
An
out-of-pocket maximum is the most you would have to pay
out of your own pocket for eligible expenses. Not all plans
have an out-of-pocket maximum. Check your Benefits Summary
for details. With a plan that has an out-of-pocket maximum,
once you reach the out-of-pocket maximum for a given year,
the plan would pay all eligible expenses for covered services
until any lifetime maximum benefit is reached.
Not all expenses count toward an out-of-pocket maximum.
Expenses for services that are not covered under the plan,
amounts over any allowable amount limit, and penalties for
not preauthorizing care when needed would not count toward
your out-of-pocket maximum.
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What is a lifetime maximum?
A
lifetime maximum is the most that will be paid by the plan
for covered services for a given plan member. Not all plans
apply a lifetime maximum, and some plans have different
lifetime maximums for different services or for in-network
and out-of-network services. Once you reach the lifetime
maximum, you pay all expenses over that amount.
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