Sometimes, navigating your health care options can feel like wandering through a poorly lit maze. There are so many different options, each with its own acronym that it can be hard to keep them all straight. For example, you may have heard that the flexibility of PPO plans makes them a better option for many families. If your employer offers Cigna's Open Access plans, you're in luck: Open Access is a PPO plan, so you continue with your current caregivers if you choose.
What PPO Means
The acronym PPO stands for Preferred Provider Organization, which points out its main difference from the more familiar Health Maintenance Organization, or HMO. With an HMO, you can only use caregivers who are part of the HMO's network. For example, if you needed to see a cardiologist, you'd have to go to your in-network primary care physician to get a referral to an in-network cardiologist. That can be inconvenient, or an outright hardship, if you live in an area where the HMO has few caregivers in its network. With a PPO, things are different. You can continue to see your own physician for ongoing care, and you won't need a referral to see a specialist. The plan does distinguish between caregivers who are within the company's network and those who aren't, which is where the "preferred" part comes in. You can see whichever doctor you choose, whenever you choose, but you'll pay more if they're outside the PPO's network.
Cigna's PPO plans follow that pattern. You'll have a substantial network of care providers to choose from, but if you opt to go outside of the network you'll pay a premium. For example, state employees in Tennessee have an annual deductible of $500 per person or $1,250 per family for in-network care, which doubles for out-of-network care. Co-pays for many services jump from 10 percent in network to 40 percent out of network, and routine preventive care such as annual checkups for adults and well-baby visits for infants — which are free in network — cost $45 each when you see an out-of-network caregiver. In the state employees' plan, the maximum out-of-pocket expense for a family is capped at $9,000 in network and $10,000 out of network, but the difference can be more in other plans.
Cigna Open Access
Cigna's range of Open Access plans are also PPO plans at heart, but they offer access to a larger national network of health care providers. Again, you have access to caregivers outside the network, but you'll pay for the privilege. The exact figures will vary with your plan and employer; for example, the Episcopal Church Medical trust shows an annual deductible of $500 per person or $1,000 per family for in-network care, but double that amount for out-of-network care. There are similar differences in the co-pay amount for some procedures and services, and the annual cap on your out-of-pocket spending rises from $5,000 per family to $13,000 per family. Some employers, such as shipping company Matson Inc., offer "Low Option" and "High Option" versions of these plans. The low option reduces your premium, but increases your deductibles and co-pays, while the high option does the opposite. In this instance, for example, the annual deductible for in-network care drops from $3,000 per family to just $600 per family.
The Fine Details
With both plans, you're encouraged — but not required — to have a primary care provider to take overall responsibility for coordinating your care. Emergency care is always covered by either plan, even if it's out of your network. If you're on a PPO plan, you'll have to submit claims yourself for any out-of-network care. In an Open Access plan, you may have to file your own claim, but depending on the provider, you might not. Employees on Open Access plans might also need to have some outpatient care and hospitalizations pre-approved, but with an in-network provider, you won't have to do any paperwork. Your care providers will bill Cigna directly. Before you make an appointment, it's usually a good idea to double-check which providers are in and out of the network. For example, as of 2018, all Methodist facilities in Memphis were in network for state employees, but the Baptist facilities were not. The difference can add up quickly, so it's worth investing a few minutes reading your employee handbook or checking online.