Preferred Provider Organization (PPO)

by Guest » Mon Aug 04, 2008 04:49 pm
Guest

What is a PPO plan?

A PPO plan or a Preferred Provider Organization plan is a very common and very popular managed health care plan.

How do PPO does plans work?

A PPO plan allows the policyholder (you) to choose the medical provider of your choice. It works like an HMO where you pay a fixed monthly premium and receive health care benefits. However, under a PPO health plan there is no provision for a primary care physician. Hence if you want to see a specialist you do not need to get any referrals.

If you opt to visit a doctor outside the network of doctors provided under PPO health plans, you will have to pay higher co-payments.

What are the advantages of PPO health plans?

  • A PPO health plan offers you more choice on physicians.

  • A PPO plan does not limit you to any one particular hospital or only a certain set of doctors. You can choose from almost any medical facility or provider.

  • If you choose a medical provider outside the network, part of your medical costs will still be borne by the insurance provider and part of it has to be borne by you.

  • If you need to see a specialist you do not need any referral like in HMO. This is a self-referral system and you will have to pay out-of pocket. This means that you are at liberty to decide whether you want to see a specialist or not.

What are the disadvantages of PPO plans?

Like other managed care plans, PPO plans too have their own disadvantages.
  • PPO plans are quite flexible and hence usually cost more.
  • The premiums and the deductibles in a PPO insurance plan are usually high.
  • PPO plans usually have co payments and prices do add up in PPO health plans.

How much will a PPO health insurance plan cost?

PPO health plans are usually expensive. Even though it has a similar structure like that of HMOs, there are other fees associated with it that increases its cost to a good extent. There are coinsurances that you may need to pay. Sometimes the coinsurance may be replaced by co payments. If you choose a non network care, you may have to pay a certain amount as deductible before you can receive health insurance benefits. Again you may also be required to pay the difference between what your health care provider charges and what your plan actually pays.

However, don't let the expenses scare you because this plan gives you the flexibility to choose the medical provider of your choice. This is a popular plan because it rests the decision on you and not the insurance company as to what kind of medical provider you need to or want to go to.

How are PPO and HMO different?

PPO (Preferred Provider Organization)HMO (Health Maintenance Organization)
Have more options when it comes to choice of physicians.Health care provider must be chosen from a selected list of physicians.
Does not limit policyholder to one particular hospital or a set of doctors.You will be limited to doctors from a fixed list of care providers.
For physicians outside network, the PPO plan pays partly and part of it must be paid by you.For physicians outside the network, you will have to pay out-of-pocket. The plan does not cover.
PPO plans are expensiveHMO plans are comparatively less expensive than a PPO plan.

What is a dental PPO plan?

Dental PPO plan is a very common type of managed care dental insurance plan where you can obtain care through a set network of dental care providers at reduced costs. Such plans usually require you to pay a deductible. If you are a member of a dental PPO plan, you may opt for a dentist from within the network. But in such a case you will have to pay a certain percentage (usually 20%) of the total cost of treatment and your insurance provider will pay the rest (usually 80%).

If you choose to go to a dentist outside the network, your insurance company will reimburse only that much amount that a dentist from within the network would have accepted.

What are the advantages of dental PPO plan?

  1. A PPO dental plan allows you the flexibility to choose dental care provider from outside their network. However, many plans do offer discounts if you choose a dental care provider from within the network.

  2. You can get low deductible options with a PPO dental plan. Again there may also be plans that require no deductibles at all.

  3. Many dentists prefer to be enlisted in the network of the PPO dental plans due to the immediacy of payment. Hence, the dentists are keener on working with policyholders who opt for dental care from within the network.

  4. There is usually no wait time or even if there is a wait time, it is very small for the basic services and preventative care.

  5. Some insurance companies provide you with a card that you cam use at the care provider instead of carrying paper works.

What are the disadvantages of PPO dental plan?

  1. Dentists in a PPO plan can simply turn away patients whose policy will not pay them. This is when you opt to visit a dentist outside the network.

  2. Most of the policies do not have deductibles. Deductibles can add up if there are several members covered in the policy.

  3. Choosing out-of-network dentists often provide lesser benefits than choosing a dentist from within the network. If you opt for out-of-network dentists you may have to pay higher costs and increased premiums too.

  4. The PPO dental plans can be restrictive when it comes to benefits. The benefits received usually have limits beyond which you will not be reimbursed.
PPO plans have their own advantages as well as disadvantages. They attract individuals with their flexibility and on the other hand they may be expensive too. Carefully consider the pros and cons of a PPO plan before you settle for one.

What is a PPO? What are PPO Codes?

Total Comments: 9

Posted: Mon Aug 04, 2008 06:59 pm Post Subject:

I know it as Prefered (or Participating) Provider Organization. It's a managed care health plan. I've never heard of "PPO Codes".

Posted: Tue Aug 05, 2008 05:43 am Post Subject:

PPO is a form of managed health care plans, designed to offer discounted or subsidized healthcare benefits to the beneficiaries of this plan. This system offers the benefit to the member to choose from the wide network of health care providers for his health related needs.

Regards,
Juanita

Posted: Tue Aug 05, 2008 05:58 am Post Subject:

the PPO is pretty similar to HMO, but offers more flexibility by allowing the member to visit a doctor outside the network. With PPO plan you are required to make regular monthly payment to enjoy the health coverage benefits.

However, with PPO you're not required to obtain the referral from the primary care physician in order to visit a specialist. You can also consult a doctor of your choice only by bearing a larger share of the expense.

~Jeremy

Posted: Wed Aug 06, 2008 04:41 am Post Subject:

The most important things to know about PPOs is:


  • You can go to any doctor.

  • You will be charged extra if you go outside of your network.

  • No extra charges for non-emergency treatment when out-of-network


In contrast an HMO will not pay anything if you seek care outside of the network, unless the charges are for treatment that was classified as an emergency.

Posted: Wed Aug 06, 2008 05:04 am Post Subject:

PPO insurance is a Managed Care health plan. You can read about it here: PPO Health Insurance. It is a mixture of the Indemnity plan and HMO plan.

links removed as per forum rules

Posted: Wed Aug 06, 2008 02:42 pm Post Subject:

I've never heard of "PPO codes" either. Could somebody elaborate on "PPO codes?"

Posted: Tue Aug 12, 2008 04:55 am Post Subject: PPO Codes

Supposedly, these are the PPO codes: 65, 71, 72, 73, 74, 75, 76, 81, 82, 83, 84, 85, 86, 91, 92, 93, 94, 95, 96, J1, J2, J3, J4, J5, J6, J9, LC, LD, LE, LM, LN, LO, N8, N9, O1, O2, P3, O4, O5, O6, O9, P8, P9, P0, RK, RM, RN, RO, RQ. I had never heard of them myself but I found one website that had them listed. It appears that these are the "PPO codes" for CommunityCare of Oklahoma. The codes are listed on the actual insurance card of the policyholder and each code corresponds with a specific package that is offered. For example, code 65 is their "Value Advantage 2 Plus (80/50)" plan. I guess they are just asking for what types of packages are offered with a PPO plan? Not entirely sure, but those are what PPO codes look like. Sounds to me like that is more of a specific healthcare company jargon that breaks down their ID card numbers or something so they know what kind of plan they are dealing with when the customer calls in and says their account number.

Posted: Sat Aug 23, 2008 05:41 am Post Subject:

Me too haven't heard about the PPO codes ? I think what insurance files is trying to say is only limited to a few states ..

Posted: Sat Aug 23, 2008 09:01 am Post Subject:

Excellent information, InsuranceFlies. I never knew that such thing exists.

However, to me the numbers seem more like random (may be they are not :roll:) Can you just share some more information regarding the PPO codes.

What are the other states that apply such policy of identification? or, is it specific to Oklahoma??

~Jeremy

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