A type of managed care health insurance plan that allows members to receive healthcare services from both in-network and out-of-network providers. However, there are financial incentives for using providers within the network.

In-Network:

Healthcare providers, including doctors, hospitals, and clinics, that have contracted with the insurance company to provide services at discounted rates to plan members.

Out-of-Network:

Healthcare providers that have not contracted with the insurance company. While PPO plans often cover out-of-network services, they usually come with higher costs for the insured individual.

Copayment (Copay):

A fixed amount that insured individuals pay for covered services, such as doctor visits or prescription medications, at the time of service.

Deductible:

The amount an insured individual must pay out of pocket for covered services before the insurance plan begins to cover costs.

Coinsurance:

A cost-sharing arrangement where the insured individual pays a percentage of the total cost of covered services, with the insurance plan covering the remaining percentage.

Preauthorization:

The requirement for obtaining approval from the insurance company before receiving certain medical services or treatments, ensuring coverage and cost-sharing compliance.

Provider Network:

The list of healthcare providers, facilities, and professionals that have agreed to provide services to members of a PPO plan at negotiated rates.

Primary Care Physician (PCP):

A designated healthcare provider, often a family doctor or internist, who serves as the main point of contact for the insured individual and coordinates their healthcare services.

Specialist:

A healthcare provider with expertise in a specific area of medicine, such as a cardiologist, orthopedist, or dermatologist.

Referral:

Authorization from a primary care physician for a plan member to receive care from a specialist or another healthcare provider.