Is a California PPO Right for You?

A California PPO (or preferred provider organization) is a form of managed healthcare that is made up of a network of doctors, hospitals, and a variety of other healthcare professionals who provide medical services to insured members for a reduced fee. A California PPO is very similar in nature to a California HMO (health maintenance organization) however it is different in that healthcare services are paid for as they are administered and not, as in an HMO, in advance of a fee that is already predetermined.

A California PPO allows for a certain degree of flexibility as a patient is allowed to go outside of the unit for medical services. However visits “out-of-network” will cost the insured member more money but not amounts that are too high. When a member stays within the PPO they only have to worry about paying a small fee. When it comes to care sought outside of the California PPO there is often a deductible to be paid and higher co-payments for services rendered.

It is necessary to choose a primary care physician when you become a part of a California PPO and it is through this doctor that all of your tests and referrals to specialists must come. Every time an insured member visits the doctor he or she must submit a claim to the California PPO and from there he will be reimbursed for the cost of the visit. The co-payment however is not part of the reimbursement.

If you are considering a California PPO there are certain questions that you need to ask beforehand in order to make an informed decision. First of all how many physicians are you able to choose from? Who exactly are the physicians that are a part of the PPO unit? Where are the doctors in the network to be found? Which one of the doctors in the PPO network is currently accepting new patients? What is the process needed to be referred to a specialist?

Hospitals must be a consideration as well. What hospitals are a part of the PPO? Where are the hospitals located in relation to your residence? How does the PPO handle care on an emergency basis? What about the services that the PPO covers, are there many or few? Is preventative services a part of the PPO or not? Does the PPO impose limits on such things as prescription drugs, medical tests, mental health care and care required outside of the hospital?

Finally consider what a California PPO is going to cost you in the short and long term. How much are the monthly premiums and do you have to make co-payments every time you visit the doctor? Take all of these things into careful consideration.