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What is a preferred provider organization (PPO) plan, and how does it work?
With a PPO plan, do I name a primary care physician (PCP)?
What are the advantages of obtaining my care from in-network providers?
How does the PPO plan work when I go out-of-network?
When do I need to file a claim form?
What happens if I need specialty care that is not available from in-network providers where I live?
What happens in an emergency?
What happens if I need care while I'm traveling?
What is a deductible?
Are there expenses that don't count toward my deductible?
What is coinsurance?
What is a co-payment?
What is preauthorization?
What's the amount known as the "allowable amount," the "U&C amount" or the "R&C amount"?
What are covered services?
What is an out-of-pocket maximum?
What is a lifetime maximum?



What is a preferred provider organization (PPO) plan, and how does it work?

A preferred provider organization (PPO) plan works for you in two ways: through a panel or network of physicians and other service providers (such as hospitals and labs), or through providers you select that are not in the network. Each time you or a covered family member needs care, you choose whether to see an in-network or an out-of-network provider.

Network providers are listed in your plan's provider directory. When you use an in-network provider, also called "going in-network," you generally receive a higher level of benefits. Also, fees from in-network providers tend to be lower, because the providers and the network have negotiated to have the providers accept certain fees for certain services.

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With a PPO plan, do I name a primary care physician (PCP)?

The PPO plan does not require you to name a primary care physician (PCP) or coordinate your care through a particular doctor. However, you are free to choose a primary doctor, whether or not that doctor participates in the network.

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What are the advantages of obtaining my care from in-network providers?

There are several advantages when you go in-network. Generally:
You may not need to pay a deductible, or your deductible may be lower than it would be for out-of-network expenses.
You don't need to submit claim forms and wait to be reimbursed by your plan.
Your in-network provider obtains any needed preauthorization for you.
You generally receive a higher level of benefits because participating providers (doctors, hospitals and other health care facilities) have agreed to provide their services at lower fees.
Some plans provide preventive care services in-network that are not covered out-of-network.
Some plans limit covered services out-of-network, but offer these services without a limit on the number of visits when the care is provided in-network.

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How does the PPO plan work when I go out-of-network?

Generally, you may use any covered health care provider you choose. However, your cost will generally be higher and you have certain added responsibilities. For example:
Each year, you must pay part of your eligible out-of-network expenses before the PPO plan begins to pay benefits. This amount is called the deductible.
After you satisfy the deductible, the plan will reimburse you for a percentage of your eligible expenses and you will pay the balance. The percentage you pay is called your coinsurance percentage.
You must get preauthorization for certain covered expenses such as a hospital stay. If you don't get the required preauthorization, the amount of benefits available will be reduced or the expenses will not be covered at all. This means your cost will be higher.
You must complete claim forms and file claims with your health care company to receive payment of benefits.
The plan will not cover any benefit reductions due to failure to preauthorize certain treatments.
The plan will not cover any charges above the allowable amount.

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When do I need to file a claim form?

You may not need to file a claim form when you see in-network providers.

When you do need to file a claim form, as you need to do in most cases when you go out-of-network, your doctor may handle your expense in one of two ways. Most doctors require you to pay the bill right away. In this case, get a receipt and file it with a claim form to be reimbursed. If the expense is covered, you will be reimbursed for part of the bill. To file a claim, follow the instructions on the claim form. If you have more than one health insurance plan and have received an Explanation of Benefits (EOB) form from another health care plan, be sure to include a copy with your claim.

Sometimes doctors are willing to wait for payment. In this case, you or your doctor will file the receipt and completed claim form with your health care company. The health care company will pay the doctor for the part of your expense the plan will cover. The doctor will then bill you for the part the plan did not pay.

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What happens if I need specialty care that is not available from in-network providers where I live?

You may be referred to an out-of-network provider if you need specialized care that your health care company determines to be medically necessary and that is not available through an in-network provider in your area. As long as you use the provider you're referred to by your health care company and follow your plans rules, you'll be covered for that care at in-network benefit levels.

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What happens in an emergency?

In a true emergency, get the care you need as quickly as you can. If you are able, contact member services for your health care company at the number on your ID card, even in an emergency. However, even if you are unable to contact member services, get the care you need. Even if you need to go out-of-network, your plan will cover emergency care at in-network benefit levels as long as you follow the plan rules.

Check to see how your plan defines a true emergency. Examples typically include severe bleeding, chest pain, and unconsciousness. Also check to see how soon after the onset of the emergency you must notify your health care company in order to be covered in-network.

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What happens if I need care while I'm traveling?

If it's not an emergency and you need care while traveling, call member services for your health care company at the number on your ID card. Member services can refer you to an in-network provider.
In a true emergency, get the care you need as quickly as you can. If you are able, contact member services even in an emergency, and your health care company can help you decide where to go for care. However, even if you are unable to contact member services, get the care you need. Even if you need to go out-of-network, your plan will cover emergency care at in-network benefit levels as long as you follow the plan rules.

Check to see how your plan defines a true emergency. Examples typically include severe bleeding, chest pain, and unconsciousness. Also check to see how soon after the onset of the emergency you must notify your health care company in order to be covered in-network.

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What is a deductible?

A deductible may only apply, or may be higher, when you obtain care out-of-network. A deductible is the part of eligible expenses you must pay before the plan begins to pay a percentage of your eligible expenses.

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Are there expenses that don't count toward my deductible?

Yes. Some of your expenses will not count toward your deductible. For example, any penalty you may pay because you failed to preauthorize treatment through your health care company will not count. For out-of-network care, amounts your care provider charges above the plans allowable amount for a given service also will not count toward your deductible.

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What is coinsurance?

Coinsurance may only apply to out-of-network care. After you satisfy the deductible, the plan will reimburse you for a percentage of your eligible expenses for out-of-network care and you will pay the balance. The percentage you pay is called your coinsurance percentage.

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What is a co-payment?

A co-payment generally applies to in-network care. When you stay in-network, you pay only a fixed amount at the time you receive services. That amount is called your co-payment.

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What is preauthorization?

Preauthorization is the process by which a health care company or preauthorization company reviews the proposed treatment and tells you and your doctor how benefits may be paid. If you receive care out-of-network, you must obtain preauthorization for certain covered expenses such as a hospital stay. Some plans also require preauthorization for certain in-network services. If you don't get the required preauthorization, your cost will be higher because the benefits payable by the plan will be reduced or the expenses will not be covered at all.

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What's the amount known as the "allowable amount," the "U&C amount" or the "R&C amount"?

The terms "allowable amount," "U&C amount" or "R&C amount" vary by plan but refer to the same thing. The allowable, usual and customary or reasonable and customary amount is the amount usually charged for a given service by most providers in your area. This amount is determined by your health care plan. If your doctor charges you more than this amount, you will not only be responsible for your deductible and coinsurance, but also for the entire difference between the U&C amount and the amount your provider charged. This concept only applies to out-of-network care, because in-network providers have agreed to negotiated fees that are by definition allowable amounts.
For example, suppose you receive a service for which the "U&C amount" is $100 but your doctor charges you $110. The health care company will multiply the percentage the plan pays for that service by $100. So even if the service were covered at 100%, you would pay the $10 difference ($110 charge minus $100 U&C).

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What are covered services?

Covered services are services covered by the plan. No medical plan covers everything. If you obtain services that are not covered services, you pay the full cost for those services.

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What is an out-of-pocket maximum?

An out-of-pocket maximum is the most you would have to pay out of your own pocket for eligible expenses. Not all plans have an out-of-pocket maximum. Check your Benefits Summary for details. With a plan that has an out-of-pocket maximum, once you reach the out-of-pocket maximum for a given year, the plan would pay all eligible expenses for covered services until any lifetime maximum benefit is reached.

Not all expenses count toward an out-of-pocket maximum. Expenses for services that are not covered under the plan, amounts over any allowable amount limit, and penalties for not preauthorizing care when needed would not count toward your out-of-pocket maximum.

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What is a lifetime maximum?

A lifetime maximum is the most that will be paid by the plan for covered services for a given plan member. Not all plans apply a lifetime maximum, and some plans have different lifetime maximums for different services or for in-network and out-of-network services. Once you reach the lifetime maximum, you pay all expenses over that amount.

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