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PPO only Health Insurance

A

Aimster

Lifer
I selected the health insurance today from my job. I had a choice between HOA and PPO.

I selected a plan that is PPO only. There is no non-PPO. I never go to the doctor so I don't care to spend $60/month more to cover some non-PPO expenses.

However, what if it is an emergency and I have to be rushed to the hospital and the hospital is not part of the PPO network.
Am I screwed? Maybe that factor alone is worth the extra $60/month.
 
There is no specific answer. It's whatever your insurance company decides. You need to read your EOB (Explanation of Benefits). However, insurance companies usually reserve the right to change your plan for any reason, even within your "contract" year.

 
Emergencies are emergencies and are covered anyway.

Unless it wasn't really an emergency, of course. 😀
 
Originally posted by: LTC8K6
Emergencies are emergencies and are covered anyway.

Unless it wasn't really an emergency, of course. 😀
Click to expand...

Actually some insurance companies require you to contact them in the event of an emergency and get pre-approval for out of plan services.

Depending on the nature of the emergency you can often get them to waive this after the fact, especially in critical, time sensitive emergencies. But if they decide differently, you can get really screwed.
 
With American insurance, you'd better hope there is a god and pray to him hourly if you have a claim. Its the only way they'll actually pay. You need a divine miracle.
 
Looks like I will be covered:

(1) Medical emergency or accidental injury care in a hospital emergency room and related
ambulance transport as described in Section 5(d), Emergency services/accidents;
(2) Professional care provided at Preferred facilities by Non-preferred radiologists,
anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency
room physicians, and assistant surgeons;
(3) Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred
laboratories, radiologists, and outpatient facilities;
(4) Services of assistant surgeons;
(5) Special provider access situations (contact your Local Plan for more information); or
(6) Care received outside the United States and Puerto Rico.
Unless otherwise noted in Section 5, when services of Non-preferred providers are covered in a
special exception, benefits will be provided based on the Plan allowance. You are responsible for
the applicable coinsurance or copayment, and may also


Had to google the information for the plan I selected as this information was not available to me.
 
Originally posted by: her209
Originally posted by: lokiju
Ummm.

HOA? Do you maybe mean HMO?
Click to expand...
Or HSA.
Click to expand...

Fuckin' HOAs control everything! First you can't paint your gutters the color you want, now they want to restrict the color of the cast when you break your leg!

What? Got a light-blue leg cast instead of off-white? LIEN!

Bastards!
 
Originally posted by: Aimster
Looks like I will be covered:

(1) Medical emergency or accidental injury care in a hospital emergency room and related
ambulance transport as described in Section 5(d), Emergency services/accidents;
(2) Professional care provided at Preferred facilities by Non-preferred radiologists,
anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency
room physicians, and assistant surgeons;
(3) Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred
laboratories, radiologists, and outpatient facilities;
(4) Services of assistant surgeons;
(5) Special provider access situations (contact your Local Plan for more information); or
(6) Care received outside the United States and Puerto Rico.
Unless otherwise noted in Section 5, when services of Non-preferred providers are covered in a
special exception, benefits will be provided based on the Plan allowance. You are responsible for
the applicable coinsurance or copayment, and may also


Had to google the information for the plan I selected as this information was not available to me.
Click to expand...

not available to you? you mean you dont have it handy or they just plain didnt give you any information? 😕
 
Originally posted by: Aimster
Looks like I will be covered:

(1) Medical emergency or accidental injury care in a hospital emergency room and related
ambulance transport as described in Section 5(d), Emergency services/accidents;
(2) Professional care provided at Preferred facilities by Non-preferred radiologists,
anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency
room physicians, and assistant surgeons;
(3) Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred
laboratories, radiologists, and outpatient facilities;
(4) Services of assistant surgeons;
(5) Special provider access situations (contact your Local Plan for more information); or
(6) Care received outside the United States and Puerto Rico.
Unless otherwise noted in Section 5, when services of Non-preferred providers are covered in a
special exception, benefits will be provided based on the Plan allowance. You are responsible for
the applicable coinsurance or copayment, and may also


Had to google the information for the plan I selected as this information was not available to me.
Click to expand...

not available to you? you mean you dont have it handy or they just plain didnt give you any information? 😕
 
Same issue if you have an HMO. In fact, PPO generally allows more choice than HMO. I would think that the plan would have an exemption for true emergency services.
 
Originally posted by: Mermaidman
Same issue if you have an HMO. In fact, PPO generally allows more choice than HMO. I would think that the plan would have an exemption for true emergency services.
Click to expand...

Sorry, he's got an HOA as his other option. No HMO.

Must be Obama's new health care plan.
 
Originally posted by: xSauronx
Originally posted by: Aimster
Looks like I will be covered:

(1) Medical emergency or accidental injury care in a hospital emergency room and related
ambulance transport as described in Section 5(d), Emergency services/accidents;
(2) Professional care provided at Preferred facilities by Non-preferred radiologists,
anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency
room physicians, and assistant surgeons;
(3) Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred
laboratories, radiologists, and outpatient facilities;
(4) Services of assistant surgeons;
(5) Special provider access situations (contact your Local Plan for more information); or
(6) Care received outside the United States and Puerto Rico.
Unless otherwise noted in Section 5, when services of Non-preferred providers are covered in a
special exception, benefits will be provided based on the Plan allowance. You are responsible for
the applicable coinsurance or copayment, and may also


Had to google the information for the plan I selected as this information was not available to me.
Click to expand...

not available to you? you mean you dont have it handy or they just plain didnt give you any information? 😕
Click to expand...

I had like 15 choices to pick from.
I'm sure it is available, but I wouldn't know where to get it from.

Federal Govt
 
If it's like most group insurance plans I've seen lately, they will only pay 80-85% of "out of network" healthcare services, and only up to a specified limit which varies on the plan. I've seen some horrible plans with out of network coverage as low as $2,000 a year, but most are better than that. If your plan has a deductible or co-pay, those might be higher for out of network coverage as well. The only way to be sure is to read the entire policy... the BIG packet that they send you after you sign up, not the little sales brochure that they give you before you fill out the application.

Look at the bright point, at least it's not private insurance. If it was, you better not get really sick during your first 18 months of coverage! If you do, they'll go through your medical history with a fine toothed comb looking for anything that could be considered to be a pre-existing condition. If they find one, expect to get a bunch of claim rejection letters from your insurer and large medical bills from the hospital. Trust me... I've experienced it first hand.
 
Originally posted by: Aimster
Originally posted by: xSauronx
Originally posted by: Aimster
Looks like I will be covered:

(1) Medical emergency or accidental injury care in a hospital emergency room and related
ambulance transport as described in Section 5(d), Emergency services/accidents;
(2) Professional care provided at Preferred facilities by Non-preferred radiologists,
anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency
room physicians, and assistant surgeons;
(3) Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred
laboratories, radiologists, and outpatient facilities;
(4) Services of assistant surgeons;
(5) Special provider access situations (contact your Local Plan for more information); or
(6) Care received outside the United States and Puerto Rico.
Unless otherwise noted in Section 5, when services of Non-preferred providers are covered in a
special exception, benefits will be provided based on the Plan allowance. You are responsible for
the applicable coinsurance or copayment, and may also


Had to google the information for the plan I selected as this information was not available to me.
Click to expand...

not available to you? you mean you dont have it handy or they just plain didnt give you any information? 😕
Click to expand...

I had like 15 choices to pick from.
I'm sure it is available, but I wouldn't know where to get it from.

Federal Govt
Click to expand...

i'm on kaiser hmo. it was the cheapest - $60/month
 
Originally posted by: dbk
Originally posted by: Aimster
Originally posted by: xSauronx
Originally posted by: Aimster
Looks like I will be covered:

(1) Medical emergency or accidental injury care in a hospital emergency room and related
ambulance transport as described in Section 5(d), Emergency services/accidents;
(2) Professional care provided at Preferred facilities by Non-preferred radiologists,
anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency
room physicians, and assistant surgeons;
(3) Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred
laboratories, radiologists, and outpatient facilities;
(4) Services of assistant surgeons;
(5) Special provider access situations (contact your Local Plan for more information); or
(6) Care received outside the United States and Puerto Rico.
Unless otherwise noted in Section 5, when services of Non-preferred providers are covered in a
special exception, benefits will be provided based on the Plan allowance. You are responsible for
the applicable coinsurance or copayment, and may also


Had to google the information for the plan I selected as this information was not available to me.
Click to expand...

not available to you? you mean you dont have it handy or they just plain didnt give you any information? 😕
Click to expand...

I had like 15 choices to pick from.
I'm sure it is available, but I wouldn't know where to get it from.

Federal Govt
Click to expand...

i'm on kaiser hmo. it was the cheapest - $60/month
Click to expand...

Be careful with that... it's probably the cheapest for a reason. With a monthly rate that low, it probably has an absurdly low annual cap (like $5,000) on many types of procedures.
 
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