Individual & Family PPO Plans

About Blue Cross of California

Blue Cross of California has been serving the health insurance needs of California residents since 1937. Blue Cross of California, together with its branded affiliates, provides health care services to more than 6.8 million members.

Offering a full continuum of product and coverage options, Blue Cross provides customers with unparalleled choice and flexibility in meeting their health plan needs. These options are continually fine-tuned to enhance access to affordable, quality health care. The Company, with its strong track record for innovation, focuses on progressive products and services designed to improve the health status of all Californians. Unique product offerings available in the individual, small group, large group, senior and Medi-Cal markets include a full range of integrated medical and specialty products.

Further to our support of the Blue Cross and Blue Shield Association, Blue Cross of California is committed to lifting the quality of public debate on issues that affect health care coverage.

Preferred Provider Organizations (PPOs)
A Preferred Provider Organization (PPO) provides a list of contracted "preferred" providers from which to choose. You receive the highest monetary benefit when you limit your medical care services to those providers on the list. If you go to a doctor or hospital that is not on the preferred provider list referred to as going "out-of-network", then the plan covers a smaller percentage of your medical care expenses or may cover none of your medical care expenses based on the contract wording of the plan. Always check with your PPO or consult your list of preferred providers before you seek medical care services to make certain your physician or hospital is a contracting provider (part of the network). Make sure that your doctor refers you to medical care providers within your PPO network, if applicable.

PPOs in California can be regulated by either the CDI or the Department of Managed Medical Care (DMHC) depending on whether the underwriting company (the company backing the policy) is a licensed insurance company or a managed care company. The DMHC has sole jurisdiction over Blue Cross/Blue Shield PPO medical plans. If you are confused about whom to call regarding a PPO problem or concern, then consult your plan documents for regulatory information. If there is still some question, then you can reach the CDI or the DMHC for assistance at the contact information given in the "Resources" section of this brochure.

Important Points to Remember About Preferred Provider Organizations:

You receive the highest monetary benefit when staying within the PPO network.
You may have the option to go outside the PPO network at a higher monetary cost to you.
You should consider checking if your doctor or any specialist referred to you is part of the PPO network before utilizing covered services.
You can seek the assistance of the DMHC on all Blue Cross/Blue Shield PPO medical plans.
You can contact either the CDI or the DMHC for clarification regarding PPO issues.

About PPO and POS Plans

PPO and POS plans are kinds of California medical insurance plans. Like an HMO, these plans have provider networks, but you can choose to see doctors outside of the network and pay more.

The Department of Managed Medical Care (DMHC) oversees Blue Cross of California and Blue Shield of California PPO medical plans. The California Department of Insurance oversees most other PPOs in California.

PPO Plans

A PPO is a preferred provider organization. A PPO is good plan for people who want to see providers without prior approval from their plan or medical group and who do not want to choose a primary care doctor.

You get your medical care from a network of doctors and other providers, but you can choose to go outside of the network and pay a higher cost.
You usually pay a yearly deductible before the PPO starts to pay some or all of your bills.
You usually pay a co-insurance, or percent of the bill, when you get a covered service. The PPO pays the rest.

POS Plans

A POS is a point of service plan. It is a mix between an HMO and a PPO.

You have a primary care doctor and you get most of your medical care from an HMO network.
You can choose to see doctors and other providers outside of the HMO network, but you will have to pay a much higher cost than if you stayed in the HMO network.

Out-of-Network PPO Costs

It is important to read your Evidence of Coverage (the booklet that explains your benefits) to understand the costs you will have when you go outside of the network in a California PPO plan. If you see a doctor or other provider who is not in your medical plan's network, you and your plan share the cost of the service. However, your cost will usually depend on the plan's Maximum Allowable Amount for the service. This is the most your plan will pay for a service. It is usually about the same as what the plan pays providers in the network.

Before you see an out-of-network doctor, you can ask your plan to tell you how much it will pay and how much you will have to pay.

Example of Out-of-Network PPO Costs

	Network Hospital (PPO pays 90%)	Out-of-Network Hospital (PPO pays 70%)
Hospital charge	$22,000	$22,000
The PPO's Maximum Allowable Amount for the service	$14,000	$14,000
Your PPO pays	$14,000 x 90% = $12,600	$14,000 x 70% = $9,800
You pay	$14,000 x 10% = $1,400	$14,000 x 30% = $4,200 plus all of the amount over the allowed cost: $22,000 - $14,000 = $8,000 $4,200 + $8,000 = $12,200