An employee becomes insured under a PPO plan provided by his employer. If the insured decides to go to a physician who is not a PPO provider, which of the following will happen? A The insured will be required to pay a higher deductible. B The PPO will pay the same benefits as if the insured had seen a PPO physician. C The PPO will pay reduced benefits. D The PPO will not pay any benefits at all.

An employee becomes insured under a PPO plan provided by his employer. If the insured decides to go to a physician who is not a PPO provider, which of the following will happen? AThe insured will be required to pay a higher deductible. BThe PPO will pay the same benefits as if the insured had seen a PPO physician. CThe PPO will pay reduced benefits. DThe PPO will not pay any benefits at all.

Answer

The answer is C: The PPO will pay reduced benefits.

Explanation for each option:

A. The insured will be required to pay a higher deductible.

• This option is incorrect because while it is possible that the deductible might be higher for out-of-network services, the primary characteristic of a PPO plan is that it pays reduced benefits for out-of-network care, not necessarily that the deductible is higher.

B. The PPO will pay the same benefits as if the insured had seen a PPO physician.

• This option is incorrect because PPO plans typically offer higher benefits for in-network providers. If the insured goes out-of-network, the benefits are usually reduced.

C. The PPO will pay reduced benefits.

• This option is correct. PPO plans allow members to see any healthcare provider, but they offer higher benefits for in-network providers. If the insured sees an out-of-network physician, the PPO will still provide coverage, but at a reduced rate.

D. The PPO will not pay any benefits at all.

• This option is incorrect because PPO plans do provide some level of coverage for out-of-network services, although at a reduced rate compared to in-network services.

Summary: If an insured under a PPO plan decides to go to a physician who is not a PPO provider, the PPO will pay reduced benefits.