Preferred Provider Organizations (PPOs)
The Preferred Provider Organization (PPO) provides a list of contracted "preferred" providers from which to choose. You receive the highest monetary benefit when you limit your health care services to those providers on the list. If you go to a doctor or hospital that is not on the preferred provider list referred to as going "out-of-network", then the plan covers a smaller percentage of your health care expenses or may cover none of your health care expenses based on the contract wording of the plan.
What is a PPO?
This stands for “Preferred Provider Organization”. Basically, this is a network of health care providers who have agreed to provide certain services at agreed-upon costs for individuals whose coverage is a part of the network. (Some suggest it is best described as a discount-buying club for medical care.) You are free to use any medical provider within the network, and all will honor the agreed services and fees. If you choose to use a provider who is not an approved member of the network, your coverage may be diminished, your personal cost higher or, in some cases, benefits for non-emergency services may be totally denied. Be sure to discuss with your Trusted Choice® agent if your coverage will utilize one or more PPOs, who are the current approved providers, and how utilizing an out-of-network provider will affect your coverage.
Important Points to Remember About Preferred Provider Organizations:
- You receive the highest monetary benefit when staying within the PPO network.
- You may have the option to go outside the PPO network at a higher monetary cost to you.
- You should consider checking if your doctor or any specialist referred to you is part of the PPO network before utilizing covered services.
- You can contact either the CDI or the DMHC for clarification regarding PPO issues.
PPOs in California
PPOs in California can be regulated by either the CDI or the Department of Managed Health Care (DMHC) depending on whether the underwriting company (the company backing the policy) is a licensed insurance company or a managed care company. The DMHC has sole jurisdiction over Blue Cross/Blue Shield PPO health plans. If you are not sure about whom to call regarding a PPO problem or concern, then contact us for help and assitance to resolve any questions you might have.
Contact ZIS for Advice - California Health Insurance Office
Contact ZIS support team for experienced help and professional advice on choosing the best health insurance plan that fits your needs and to the get quality service and honest advice that you seek.
- Contact us toll free at 1- 877- 990- 3808
- Or e-mail us with your questions and request at zis@zisinsurance.com
To Contact Department of Managed Health Care (DMHC)
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
Phone: 888-466-2219
Web site: www.dmhc.ca.gov
