Welcome to Our 11th Annual PPO Survey
For this survey, seven PPOs in California diligently answered direct questions about their plans. Our readers, who are savvy health brokers, suggested many of the questions. We hope this information will help the professional agent or broker better serve sophisticated healthcare clients.
1. Is an Approval Procedure required for Getting a Specialist Referral or a Diagnostic Test or Treatment In-Network or Out-of-Network?
Aetna: There is a high tech radiology precert requirement for some customers.
Anthem Blue Cross: It is not required for PPO plans, but the member ends up paying more if they go out-of-network without getting an out-of-network approval.
Blue Shield: No, PPO plan members can generally self-refer to any doctor for care. They can choose to use in-network or out-of-network providers with claims reimbursement based on their benefit plan. Out-of-network services are usually subject to a higher deductible and co-payment amount.
Cigna: No referrals or approvals are required since the PPO benefit plan is an open-access program. Members are covered whether or not they get care from PPO network providers. Members who use services from an in-network provider may have reduced co-payments and lower out-of-pocket costs.
Health Net: There are no approval procedure requirements for visits to in-network or out-of-network specialists. A prior authorization list for diagnostic tests or treatments is included in the member’s evidence of coverage (EOC).
Kaiser Permanente: No, the PPO plan does not require a referral to see a specialist. Diagnostic tests are covered provided they are ordered by an insured’s doctor, are a covered benefit, and are deemed medically necessary.
UnitedHealthcare: To strengthen the patient-physician relationship, primary physicians are not required to request an authorization when they refer a patient to a network specialist for an office visit. Primary physicians are very effective at ensuring that our enrolled individuals receive medically appropriate and necessary specialty care. In fact, practice pattern analysis shows that primary physician referrals to network specialists have been almost 100 percent effective and medically appropriate.
2. Are there any restrictions on getting second opinions from an in-network provider or an out-of-network provider?
3. Where are decisions made about specialist referrals, testing, treatment, surgery, and hospitalization?
4. Which complementary medical disciplines are covered under the PPO or will be covered under the PPO?
The answers and all the questions up to #13 can be viewed by clicking HERE: Our Health Insurance policies are quite complicated. Please give us a shout out so we may help you understand better what the PPO Health Insurance covers.
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