Question

Maria is a PPO (preferred provider organization subscriber and received care from an out of networks provider. Which of the following is the likely result?

A) She will pay higher out-of-pocket costs.
B) She will not have to pay any medical expenses.
C) She will receive a refund for the healthcare services.
D) She will be covered by her insurance for out-of-network care.

Answer 1

Maria, as a PPO subscriber using an out-of-network provider, will likely pay higher out-of-pocket costs because PPOs cover a smaller portion of costs for services outside their preferred network.

Step-by-step explanation:

If Maria is a PPO subscriber and chose to receive care from an out-of-network provider, the likely result is: A) She will pay higher out-of-pocket costs. PPO plans offer more flexibility than HMO plans in choosing healthcare providers, but they still have a network of preferred providers which make healthcare services more affordable to their subscribers. When services are rendered by an out-of-network provider, the insurance plan will often cover a smaller portion of the costs, leaving the subscriber to pay the difference, which is substantially higher compared to in-network services.

Part B insurance typically covers external healthcare services such as physician services and outpatient visits. Even so, beneficiaries are required to contribute to the cost through deductibles and copayments, and the government subsidizes a significant part of the expenses. This helps illustrate the concept of cost-sharing, which aims to discourage moral hazard by ensuring policyholders are financially responsible for a portion of their healthcare costs. This mechanism is designed to prevent overutilization of healthcare services and encourage users to share in the financial burden of their health insurance claims.