Preferred Provider Organization (PPO)

A Preferred Provider Organization (PPO) is an independent network of providers that contracts with a health insurance company, an employer or a group of employers to provide health services at a discounted rate. A PPO cannot market insured health insurance policies on its own unless it obtains a license as an insurer or health care center.¹ PPO members may be able to seek care from a doctor or hospital that is not a preferred provider, but will probably have to pay a higher deductible or co-payment. ²

Eligibility

Any resident of Connecticut under the age of 65 is eligible for a PPO plan. Eligible dependents include a spouse and unmarried children (biological or adoptive) under 26 years of age. Disabled dependent children, regardless of age with proper documentation, are also included.

PPO Insurance is a Reimbursement Program

Members usually pay for their health care services up to an annual deductible and are then reimbursed by the health insurance company. The doctor sends the bill to the health insurance company on behalf of the member. Reimbursement for the member or their doctor depend on the policy’s co-payment and deductible, which are then subtracted.

How a PPO Works

PPO managed care plans give members access to quality care at a lower cost with the ability to make flexible health care decisions. In general, here is how a PPO works:

1. Low Cost Care and No Claim Forms: When members need care, they are free to visit any network provider listed in the PPO directory. Members pay lower out-of-pocket costs when getting care because of negotiated discounts with network providers. The plan reimburses other costs at the highest level and the provider fills out the claim forms for the member.
2. Freedom to See Other Providers: Members have the option of visiting providers that are not listed in their directory, but the plan reimburses costs at a lower level, and the member pays more out-of-pocket towards the cost of care. In this case, the member must also fill out the claim forms.
3. Approval Required in Special Cases: When a doctor recommends certain types of treatment, the member must call the medical advisors at Patient Advocate for approval. If they do not call, or treatment is not approved through the plan, benefits will be paid at a lower level.