Question 22

There is no effect on the member.

Choosing to utilize a physician outside the network in a Preferred Provider Organization (PPO) does not have a significant negative effect on the member, as they still retain access to care without requiring prior authorization.

A) The primary care physician has to authorize the treatment.

This option is incorrect because PPO plans typically do not require a primary care physician to authorize treatment, allowing members the flexibility to see specialists or out-of-network providers without referrals.

B) PPO is a closed plan.

This statement is incorrect. A PPO is an open plan that allows members to see any healthcare provider, both in-network and out-of-network, without needing to go through a closed system or requiring referrals.

C) No benefit would be available.

This option is incorrect because members still receive benefits when using out-of-network providers, although they may be subject to higher costs compared to using in-network providers.

D) There is no effect on the member.

This option is correct as members of a PPO can seek care from out-of-network providers without a significant impact on their coverage, although they may incur higher out-of-pocket expenses.

E) The member will pay more of the treatment cost.

While this statement is true in that out-of-network care typically results in higher costs for the member, it does not reflect the absence of effect on the member’s access to care, which is the focus of the question.

Conclusion

The correct answer reflects the flexibility of PPO plans, allowing members to seek out-of-network care without prior authorization or significant restrictions. Other options either incorrectly describe the requirements of PPO plans or misrepresent the member's ability to access care. Thus, the correct understanding is that while costs may vary, the member's ability to receive treatment remains largely unaffected.