Next, call the doctor's office directly to make an appointment. You can make an appointment with any physician or specialist directly without any referrals. When you get to the office, the office staff will make a copy of your medical plan ID card and you may be asked to pay your office visit co-pay or deductible, if one is required. The plan's co-insurance will not kick in until you have met your annual deductible. Generally, the co-pays do not count towards meeting the annual deductible limit. Once your annual deductible has been reached, the plan will pay its share of the remaining allowed charges that the health plan has negotiated with the doctor (i.e., its co-insurance). For in-network providers, the doctor's office will bill the health care plan directly and then bill you for the part of the bill that is your responsibility. Once the claim has been processed and paid, and you have a payment responsibility, the health care plan will send you an Explanation of Benefits (EOB) that shows the amount of payment that you owe. If you go to an out-of-network provider, some providers will require you to pay all the doctor's fees first and then submit a claim form with the provider's bill to the health care plan. Other providers will bill your health care plan for their services. You can have the health care plan reimburse you for the portion of the claim that is covered under the health care plan or pay the provider directly. You may have to satisfy a higher deductible limit for out-of-network providers. The health plan usually pays a lower co-insurance percentage for out-of-network providers. Finally, the plan may pay a percentage of reasonable and customary costs, which are rates that most doctors in the area will charge for the procedure. If the out-of-network provider charges more, you will have to pay the difference. You should always file claims so the health plan can track your deductible amount. This example illustrates the difference in costs between going to an in-network vs. and out-of-network provider for services. In this example, the doctor's normal fee is $120 for the office visit, the reasonable and customary rate is $100, and the plan's discounted fee for the office visit is $80. If the doctor is an in-network provider, the plan will pay 80 percent of the discounted fee, or $64; the employee will pay the balance of $16. If the doctor is an out-of-network provider, however, the cost to the employee will be significantly more. The plan will pay 60 percent of the $100 R&C fee, or $60. In addition, the employee will be charged the difference between the $100 R&C rate and the doctor's actual $120 billing rate. This means the out-of-network provider will cost the employee $60 ($40 plus the $20 balance of the bill) for the visit. There are several financial limits built into PPO plan designs to protect you against large out-of-pocket health care expenses. Each covered participant will have an individual deductible limit, but there is also a family deductible limit. If you cover a large family, each person will be responsible for their individual deductible up to the combined family limit. Individual deductibles from any combination of family members will apply to the family limit. Once either the individual deductible limit or the family deductible limit is met, the plan will begin paying co-insurance. Deductible limits start over every January 1.

For example, John Smith covers a family of 4 that includes his spouse and 2 children. His plan has a $200 individual deductible and a $600 family deductible limit. If only John needs health care during the year, he will be responsible for health care expenses up to his annual maximum of $200. After he reaches $200, the plan's co-insurance will begin paying. If his wife needs medical care, she will be responsible for her expenses up to her annual maximum of $200 before the co-insurance will begin. And if the two children need care, they together only have to meet another $200 in deductibles in order to reach the family deductible limit. In this example, the family reaches the $600 family deductible limit before either John or Mary reach their $200 individual deductible limit. Once the family deductible limit is reached, all family members are considered to have reached their deductible limit. A word of caution: check your plan's rules because not all expenses may apply towards the deductible, and there may be additional deductibles imposed for out-of-network providers. A co-insurance limit is also sometimes called an out-of-pocket maximum, and it is another protection built into PPO plans. A co-insurance limit is a set amount that limits the total amount of co-insurance you have to pay for the year. Once you reach the co-insurance limit, the plan pays 100% excluding co-pays, deductibles and penalties.