What is a PPO?
A Preferred Provider Organization (PPO) is a health plan that encourages the use of selected providers by reimbursing at 100% of reasonable and customary amounts, less any deductibles and co-pays. Non-network providers may be used but the reimbursement amounts are reduced. The Community Blue PPO offers a nationwide choice of providers. Plan allows flexibility by using “in network” and “out of network” services. A directory of participating physicians and facilities is available by going online to the Blue Cross Blue Shield website at: www.bcbsm.com. Once at the website, select the “Physician Search and Other Directories” icon, select the type of search (physician/facilities/urgent care locations), then select Community Blue under “choose plan” option and begin search. Effective January 1, 2007, there is a choice of two Community Blue PPO Options: Option 1 & Option 2 for most employee groups – see Health Care Information on the Benefits website at: http://www.emich.edu/hr/healthcareinfo
It is possible for an employer to deal directly with an insurer through a group sales representative to purchase group insurance. Premium rates and underwriting practices vary considerably from one insurer to another, however. In addition, the coverage provided are rarely identical. This means that comparison shopping is often beyond the capability of all but the most sophisticated purchases, for example, the very large company that has sufficient internal employee benefits expertise to do so. For this reason, many group insurance purchasers do not deal directly with insurance company underwriters or group insurance representatives, preferring instead to deal with an intermediary. Smaller employers need a qualified professional to act as intermediary because they lack the resources and expertise to handle their group insurance needs.
PPO stands for Preferred Provider Organization. This is a type of health insurance plan that offers in-network as well as out-of-network coverage. However, out-of-network coverage is typically subject to either a higher deductible or lower co-insurance than in-network, often times both. No referrals are required in order to access care.
A PPO is a medical plan with a large group or network of providers contracted to provide their services at reduced rates. The PPO allows participants to use physicians and hospitals in the BlueChoice network, without the use of a primary care provider for referrals to specialists and hospitals. The Plan provides benefits for both in-network and out-of-network services, although the plan pays higher benefits for services provided in-network.
A Preferred Provider Organization is a form of managed care closest to an indemnity plan. A PPO negotiates arrangements with doctors, hospitals and other providers who accept lower fees from the insurer for their services. As a result, your cost-sharing will be lower than if you go outside the network of providers. If you go to a doctor within the PPO network, you will pay a co-payment for certain services, such as $20 for a doctor and then your PPO insurance policy will pay the rest of the doctor’s charges, no matter what they really amount to. Another characteristic of PPOs is the ability to make self-referrals. PPO plan members can refer themselves to doctors of their choice, including specialists, as long as those providers are also part of your PPO network. With a PPO plan, you are allowed to see providers that are NOT members of the network, but in this case, your insurance company will only pay some of those charges, leaving you to pay the balance. If you have a PPO plan, in ord
