California Health Insurance - Affordable Health Insurance Quotes in California

Preferred Provider Organizations (PPOs)

A 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. Always check with your PPO or consult your list of preferred providers before you seek health care services to make certain your physician or hospital is a contracting provider (part of the network). Make sure that your doctor refers you to health care providers within your PPO network, if applicable.

PPOs in California may be regulated by either the CDI or the Department of Managed Health Care (DMHC) depending on whether the contract or policy was issued by a licensed insurance company or a managed care company. The California Department of Managed Health Care regulates HMOs and plans issued by Blue Cross of California and Blue Shield of California. The CDI regulates policies issued by insurance companies such as BC Life and Health Insurance Company and Blue Shield of California Life and Health Insurance Company. If you are confused about whom to call regarding a PPO problem or concern, then consult your plan documents for regulatory information.

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.
• Check to make sure your doctor or any specialist referred to you is part of the PPO network before utilizing covered services.
• PPOs can be regulated by either the CDI or the DMHC depending on if the company that issued the contract is a licensed insurance company, or a managed care plan. PPOs can also be self-funded. If you need assistance and you are not sure which agency regulates your plan you can contact the CDI or the DMHC for clarification.