Benefits Blog

Word of the Day - PPO

​Hi All!

Now that you know what an EPO is, let's talk about PPO - Preferred Provider Organization.  I hinted at its meaning in the EPO discussion so you might havea  general idea already.

A PPO plan uses a large national network of providers and facilities, but unlike the EPO, it provides coverage for services you receive from providers who are not in the PPO network.  For example, in the PPO plans offered by the State, in network benefits (those provided by a pracitioner in the plan's network) are paid at 90% of the allowed benefit.  Except if the service has a copay listed - then the plan pays 100% of the allowed benefit after you pay the copay.

If you receive services from an out of network provider, you pay the deductible of $250, then the plan pays 70% of the in-network allowed benefit; you pay the remaining 30% up to an annual limit of $3,000.

This is an ideal plan choice if you "just need to be sure" you have coverage if you need to receive care from a physician or facility that is not in your plan's network.  Beware: because the provider is out of network, you may be billed for the difference between the billed charges and the plan's allowed benefit.

Remember, under the EPO, there is no coverage for out of network services except for medical emergencies.