PPO insurance?

Question

Okay, I am very uneducated when it comes to insurance. Until very recently I have been under my parents insurance so I never had to worry about it. I now work in a place that offers Blue Cross Blue Shield insurance, a PPO plan. It says that I have a $500 deductible. On some of the things it will say that all I have is a $30 copay, but then on other ones (like non network for example) it will say deductible and THEN $30 copay. Does this mean on the ones where it says deductible then $30 I have to spend $500 before that copay applies, like before the insurance will pay for it? And also, what does "Network" and "Non network" mean?

Answer 1

Network: means the provider (doctor/hospital/etc.) takes your specific insurance plan. Non-network - means they either don't take the plan at all, or take a different formulation of that plan. (Common with large nationwide plans like Aetna, Blue Cross Blue Shield, United Healthcare, and others - because there are hundreds, if not thousands of networks on these plans.)

On the claims where the deductible comes into play, there's several senarios. 1. You will be paying your $30 copay - THEN probably something towards the deductible - those are often cost-sharing plans. OR 2. You have to meet the deductible first, then anything after that has the $30 copay. OR 3. The copay is for office visits, the deductible applies to any labs or xrays or anything that isn't just an office visit, or for anything done in the hospital. It's a good idea to know for sure what's allowed and what's not. If you have any questions, call member services - the number is on your card - and they can tell you what's specific to your plan.

Always offer your copay at the time of service, if the provider's office opts not to take it then, that's their policy - some prefer to bill for copays, many tack on a penalty if it's not paid up front. NEVER pay towards your deductible up front. ALWAYS have your insurance billed first. That is how your deductible is tracked to see if you've met it or not, and the insurance will tell the provider how much they can bill you - it's often much less than what you'd pay if you didn't have insurance.

Deductible is how much you have to pay out before the insurance picks up the tab.

Answer 2

The copay probably applies to your office visits and certain diagnostic tests as long as you use a doctor who is considered "participating" with Blue Cross. These are the "network" physicians, most doctors are participating with Blue Cross as it is a very popular insurance. If you go to a doctor or facility that is not considered a part of the network, that's when they penalize you with the deductible. So anytime you schedule an appointment with a new doctor, just make sure you ask. The PPO means that you can go to a specialist without a paper referral from your primary care doctor.

Answer 3

Out of network does mean that your deductible must be met before you have the $30 copay. Network is doctors in the Blue Cross Blue Shield network, this list is on the website.

Answer 4

These are great answers, but they overlook one of the best benefits of a PPO: the discount. When a provider signs on with a PPO, the agree to use PPO rates so the amount that the claim is based on starts out lower than off-the-street rates.

Example: I got charged $75 for a service that the PPO only allows $40 for. I have not met my deductible, yet. The doctor writes off $35 as PPO discount and I'm only responsible for the $40.

Answer 5

Network are providers that are contracted with BCBS. Non network are providers not contracted with BCBS. I advise to only use network providers. This way you will only be responsible for the deductible $500 and then the $30 copay. Use the BCBS on line provider directory to make sure you have the most updated list of Network providers.

Answer 6

Yes, you have to meet the deductible before the copay kicks in.

For example, if the deductible is $500 and your cost of med or RX is $250....then You would have to pay the full $250.....on subsequent visit you will pay whatever balance is remaining to cover the deductible....aftrer that, your copay kicks in.

Answer 7

What ambulance company the hospital can or chooses to use should not effect how a claim is paid. There are a couple of ways to go about this (and get the Case Manager involved in this). Is there a contracted ambulance company in the area where your daughter was hospitalized? Was this info communicated to the case manager when the medical necessity was determined and the ambulance approved? If the answer to one or both of these questions is "no", since the hospital is "in-network, ancillary providers should also be paid in-network-especially ones that you do not yourself choose, but are chosen for you by the in-network provider. Ambulance companies get caught in this all the time. Contact them to see if they have a procedure in place to get this reprocessed at the in-network rate. Sometimes they will even accept the out of network rate to save the hassle and time of getting it paid correctly. Since the claim is in process, you should contact the Case Manager and the ambulance company to see what the answers are and what solutions they offer. Your other option is to wait until it is paid and follow the appeals process with your carrier. Good luck! My prayers are with you and your little one!

Answer 8

Networks means doctors, hospitals, etc., that participate in the plan. Non-network means ones that do not.

Deductible means that you pay the first $500 in bills each year.

Copay means that you pay $30 for each of the remaining visits and insurance pays the rest.