How does an Office Visit Co-Pay work?
First of all, a PPO office visit co-pay works differently than a HMO office visit co-pay. This causes quite a bit of confusion, especially if a person has come off of a group plan HMO onto an individual PPO plan. So what’s the difference? For example, take a Blue Cross of California PPO $1500 deductible plan with a $30 office visit co-pay. When you visit the doctor for an outpatient visit such as; for the flu, or an annual check up, or even a sprained knee from the gym. As a rule of thumb, you will be responsible for all charges except for the cost of making the appointment. So if you went to the doctor because of the sprained knee, the visit itself will be covered with your office visit co-pay of $30. If the doctor says you need an X-ray, “take this slip to XYZ Radiology Associates to make sure there are not any bone chips or a slight fracture.” The X-ray charges you will be responsible for, which will be credited towards your annual deductible.
Now, your visit is for an annual physical. Your doctor usually charges $100 for an appointment, but in your case the charge is covered with your plan co-pay. During the physical your doctor says you should get your cholesterol checked one of the Blue Cross network labs. That charge will also go towards your deductible.
What about the HMO co-pay, how is that different? HMO co-pays will usually cover most of the visit costs; the office visit, any lab work and X-ray costs. An HMO plan co-pay is much more comprehensive in regards to what is covered within the co-pay.
So why would anyone choose a PPO plan? Two primary reasons:
- The monthly premiums for a PPO style plan has a much lower monthly premium then the alternative HMO plan.
- Freedom of choice with physicians, specialists and hospitals (over 42,000 providers in California). If I want to see a particular specialist, or have an operation at a certain hospital, or receive treatment from the most respected medical group, I make an appointment, and go. I don’t need a referral, I don’t need an approval from a medical group board. I’m in control. That alone is why I thing PPO plans offer much more value than HMO plans.
Some PPO’s (Preferred Provider Organization) offer plans with unlimited office visit co-pays, other plans have a limited number of co-pays per year, such as three or five, after they are used you simple pay the cost of the visit. And others offer no office visit co-pays.
Value for your money. There are so many plans and companies available today, I understand how comparing plans can be a chore. I’m here to help. Within a few minutes I will be able to narrow down the list of plans to just a few for your review. Making the comparison process much more manageable. So feel free to call anytime with your question or comments. I look forward to hearing from you.
Don’t forget about Dental coverage
John Conner
Sacramento CA
800-700-1246
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