What is a PPO?
PPO stands for Preferred Provider Organization. A PPO is a kind of health insurance or managed care plan.
Networks: Like HMOs, PPOs have a network of doctors and other providers. However, you can choose to see providers who are not in the network. You usually pay a higher cost to see providers who are not in the network.
The providers in the network have an agreement with your PPO that sets a price to provide you a service, like an office visit or surgery. These providers cannot charge you more than the set price. But a provider that is not a part of the network can charge you more. Learn more about PPO costs...
Check with your PPO plan about its provider network and about costs.
Primary care doctors and medical groups: In most PPOs you are not required to select a main doctor, also known as a primary care doctor or PCP. Some PPOs will ask you to select a doctor or a medical group that will provide most of your care. A medical group is a group of doctors and other providers that contract with a health plan.
Check with your PPO plan about its rules and network of providers.
Referrals and pre-approvals: In most PPOs, you usually can go to a specialist and get certain other services without first seeing a primary care doctor and getting a referral.
You or your doctor may need to get pre-approval from your PPO before certain treatments, procedures, or services are performed.
Check with your PPO plan about its rules regarding referrals and pre-approvals.
Why would I choose a PPO?
- You have a doctor you like and you want to keep this doctor, and the doctor is in the PPO network.
- You want to see specialists and other providers without having to get referrals and pre-approval first.
- You want more of a choice of doctors and hospitals you can go to.
- You want the freedom to see providers who are not in the network. You are willing to pay an extra cost if an out-of-network provider charges more than the PPO's allowed amount.
Why would I NOT choose a PPO?
- You want easier to understand fixed costs (such as a co-pay) instead of a percentage of service costs.
- You do not want to get bills from providers.
- You want to avoid more paperwork related to insurance claims.
The Department of Managed Health Care regulates some Blue Cross and Blue Shield PPOs.
The Department of Insurance regulates most PPOs (including some Blue Cross and Blue Shield PPOs).