The PPO, or Preferred Provider Organization, provides the highest level of choice. PPO plan members are not required to choose a Primary Care Physician, and referrals are not necessary. Members can choose to receive care for covered services from providers and hospitals that belong to Harvard Pilgrim's participating provider network or from those who don't. However, the PPO plan costs more as it has a higher premium as well as more out-of-pocket costs like deductibles and coinsurance.
Participating providers include Harvard Pilgrim's 22,000 doctors and more than 130 hospitals. Outside of Massachusetts, Maine, New Hampshire and Rhode Island, participating providers also include the Private Healthcare Systems network of more than 360,000 providers and 3,500 hospitals across the United States.
When provided or arranged by participating providers, services are typically covered at a higher level. Services received outside of Harvard Pilgrim's participating provider network are subject to more out-of-pocket costs. Here are more details:
- PPO plan members are not required to choose a PCP, and referrals are not necessary. The PPO provides the highest level of choice.
- Seek care from participating providers and you'll be covered at the in-network benefit level for covered services. Or you can choose to see providers who do not participate with HPHC and be covered at the out-of-network benefit level.
- While the PPO provides more choice, it typically has more out-of-pocket costs with coinsurance and deductibles, as well as paperwork like bills and claim forms.
- In-network coverage: Some services, like doctor's visits require a copayment, but for other services, like hospital stays, you are covered at 90% (you are responsible for remaining 10%)
- Out-of network coverage: $300 individual/$600 family deductible, then 70% coverage (you are responsible for remaining 30%)
Premium cost : Very High
(amount deducted from your pay)
Potential for out-of-pocket costs: High
(deductibles, coinsurance, etc.)