Preferred Provider Organization (PPO) Coverage and Access

110.4 – Preferred Provider Organization (PPO) Coverage and Access (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) PPOs must furnish all services in-network and out-of-network, but may charge higher cost-sharing for plan covered services obtained out-of-network. The following rules apply to PPO coverage outside the service area: • The out-of-network requirement for PPOs applies to the entire United States and its territories. For example, a PPO with a service area in Puerto Rico must cover all plan benefits furnished to its enrollees on the mainland. An MAO wishing to furnish all plan-covered services outside its service area but only in certain geographic locations should offer an HMOPOS plan; • PPO plans must provide reimbursement for all plan-covered medically necessary services received from non-contracted providers without prior authorization requirements. However, both enrollees and providers have the right to request a prior written advance determination of coverage from the plan prior to receiving/providing services; • PPO plans offering an optional supplemental benefit must offer the same benefit in- network and out-of-network; • PPO plans that cap the dollar value of supplemental benefits must use the same cap for both in-network and out-of-network benefits; and • PPO plans are prohibited from establishing prior notification rules under which an enrollee is charged lower cost-sharing when either the enrollee or the provider notifies the plan before a service is furnished.