Preferred Provider Organization (PPO)

The preferred provider organization is a combination of traditional fee-for-service and an HMO. Like an HMO, there are a limited number of doctors and hospitals to choose from. When you use those providers (sometimes called "preferred" providers, other times called "network" providers), a percentage of your medical bills are covered.

When you go to doctors in the PPO, you present a card and do not have to fill out forms. Usually there is a small copayment for each visit. For some services, you may have to pay a deductible and coinsurance.

Unlike an HMO, a PPO does not require that you choose a primary care doctor to monitor your health care. Many PPOs cover preventive care. This usually includes visits to the doctor, well-baby care, immunizations, and mammograms.

In a PPO, you can use doctors who are not part of the plan and still receive some coverage. At these times, you will pay a larger portion of the bill yourself (and also fill out the claims forms). Some people like this option because even if their doctor is not a part of the network, it means they don't have to change doctors to join a PPO.

Questions to Ask About a PPO:

• Are there many doctors to choose from?
• Who are the doctors in the PPO network?
• Where are they located?
• Which ones are accepting new patients?
• How are referrals to specialists handled?
• What hospitals are available through the PPO?
• Where is the nearest hospital in the PPO network?
• What arrangements does the PPO have for handling emergency care?
• What services are covered?
• What preventive services are offered?
• Are there limits on medical tests, out-of-hospital care, mental health care, prescription drugs, or other services that are important to you?
• What will the PPO plan cost?
• How much is the premium?
• Is there a per-visit cost for seeing PPO doctors or other types of copayments for services?
• What is the difference in cost between using doctors in the PPO network and those outside it?
• What is the deductible and coinsurance rate for care outside of the PPO?
• Is there a limit to the maximum you would pay out of pocket?

Source material from: Checkup on Health Insurance Choices. AHCPR Publication No. 93-0018, December 1992. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/consumer/insuranc.htm.