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Preferred Provider Organization (PPO) - An Overview

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Preferred Provider Organization (PPO)

Some Useful Information on Preferred Provider Organization (PPO)

People in the United States have access to innumerable types of health plans but the most common is perhaps Preferred Provider Organization (PPO) plans. So what exactly are PPO plans? The very first aspect of a PPO plan is its stature of a managed care plan. Like Health Maintenance Organization (HMO) plans, PPO plans too falls under the category of managed healthcare. But in case of the latter, flexibility is far higher since you can consult any doctor from participating providers. This is a rather unrestrictive health coverage structure where an individual has greater say in his own health decisions. On the contrary, members of HMO plans need to choose a Primary Care Physician (PCP) without whose referrals the former cannot consult physicians of their choice.

Individuals with a mind to save must always opt for Preferred Provider Organization plans for their cost effectiveness. With PPO’s, you can always have a way with both in- network and out- network providers. While in- network services are mostly covered, out- network services are covered to an extent. In case of other managed care plans like HMO’s, no coverage is offered for out- network services and products. This restriction may not be the best thing for patients who need immediate and who happen not to find it amongst participating providers.

PPO’s are ahead even where referrals are concerned. No matter what your condition is you can always self- refer to physicians within the given network and also outside it. This is a highlight that other managed care plan members do not get to avail. For example, in case of an HMO, a member always needs to take reference from his Primary Care Physician (PCP) if he has to consult specialists from within the network or outside. In fact, the restrictions increase further when members avail services from outside the network.

Everything has its set of advantages and disadvantages and this is true even for PPO plans. For one, PPO plans are really expensive and that is why most people find it difficult to pay up. Usually, all aspects of a PPO plan are pricey. So be it for the deductible, the co- insurance or the premiums, a PPO plan becomes rather pricey. People who are all for the benefits a PPO plan offers are often mislead by the premium amount stated. It is often the case, that the deductible and co- insurance amounts are so high that a low premium does not really make a difference.

It is not only the premium that’s going to bother you when you’re on a PPO plan. Co- payments are a part and parcel of the Preferred Provider Organization (PPO) structure. Every year, your PPO plan will offer you coverage for a limited number of office visits. For the rest, you’ll need to pay what is known as a co- payment. Co- payments can be anything between $10 and $30. On viewing the very first instant, it may not seem like a huge amount but along the way it actually adds upto a lot. To have a decent idea about deductibles, co- insurance and premiums, it is always good to opt for plan comparisons.


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