A Preferred Provider Organization (PPO) is an alternative type of health plan that has quickly become the most commonly recognized and available type of plan offered by insurance companies. A PPO personal health insurance plan has similarities to both an HMO and indemnity plan. Similar to an HMO plan, there is a specific group of doctors and hospitals selected by the insurance provider, referred to as “preferred providers,” because these doctors and hospitals have contracted with your insurance company to provide services to their plan members at predetermined and discounted rates.
Also like an HMO plan, there is no claim form that must be submitted by the insured member. When you receive services from a preferred provider, all claims are handled between that health care provider and the insurance carrier. However, unlike and HMO plan, you can choose to visit any physician within their network of doctors and do not need to select a primary care physician. This greater freedom of choice more closely resembles that provided under an indemnity plan. Many affordable PPO health insurance plans provide you with the ability to visit any doctor or hospital that you wish, just as you can under an indemnity plan, and typically there is no limit to the geographical area within the state. However, if you choose to visit a physician or medical facility that is not part of the PPO’s list of preferred providers, you will be required to pay a higher coinsurance percentage and may need to file you own claim form to receive reimbursement from the insurance company. Accessing a non-participating physician is referred to as going “out-of-network” and many PPO plans will place greater limitations and lower maximum benefit levels for this expanded availability.
When you enroll in a PPO plan, you will be asked to select your plan deductible and coinsurance limit. Many companies that offer PPO plans will have a unique name or brand for the different levels of affordable PPO health insurance plans that they offer. Some have low deductible with high coinsurance percentages, while others may have high deductibles with lower coinsurance percentages. Just about every possible combination of coverage limits you could imagine is available from most insurance carriers offering this type of health plan. In many cases, you can customize a PPO personal health insurance plan to best meet your budget and your medical care expectations. Once you are enrolled in a PPO health insurance plan, it works similar to an indemnity plan. You must first meet your annual deductible (when applicable) and then you will pay your coinsurance percentage for covered benefits for the remainder of the calendar year. All PPO plans provide a maximum annual co-insurance maximum, which tells you what the maximum is that you could possibly pay for covered services during the year. This is also commonly known as the annual “out-of-pocket” maximum. Not all covered services may apply to this maximum, and “out-of-network” services may have a separate maximum. Always refer to the plan details of any PPO closely for the details on coverage limits and maximums.
In choosing a PPO plan, there are several things you should consider. As with an HMO plan, you want to make sure that there are participating providers within your geographical region and that the hospitals you prefer are part of the network of preferred medical facilities. Remember, using a physician or hospital outside of the network can result in much higher deductibles and coinsurance percentages. You will also want to closely review the limitations and exclusions to make certain that the PPO personal health insurance plan will provide you with the level of coverage that you need. Choose a plan that has a deductible that you can meet financially during a calendar year. Also ask if the PPO plan gives you coverage “out-of-network.” If it does not, you want to make extra certain that most of the physicians in your area accept this plan. And, as with any type of insurance, make sure you are buying an affordable PPO health insurance policy from a company that is financially secure and is widely recognized in your state.
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