What is LPPO and RPPO Health Insurance?

LPPO and RPPO are two types of Preferred Provider Organization (PPO) health insurance plans. PPO plans allow members flexibility in choosing healthcare providers while still having access to discounted in-network rates. LPPO and RPPO plans offer regional or local provider networks respectively.

PPO Health Insurance Overview

Before diving into LPPO and RPPO specifically, let’s first understand how PPO plans work in general:

• Nationwide networks – PPOs provide access to large networks of medical providers across the U.S.

• In and out-of-network – Members can see any provider but pay less when using in-network providers.

• No referrals – PPO members can directly access specialists without a referral.

• Deductible and coinsurance – Members pay a deductible first, then coinsurance until reaching the out-of-pocket max.

• Copays for some services – Copays like $25 for office visits apply to certain services instead of coinsurance.

What is an LPPO?

LPPO stands for Local Preferred Provider Organization. Key features include:

• Local provider network – The LPPO plan contracts with providers located within a specific metropolitan area or region. This could be a single city or a small multi-county area.

• Live/work rule – Members must live or work within the LPPO’s local service area to enroll. This is the geographic area where the network providers are located.

• Lower premiums – Premiums may be lower than nationwide PPOs since the provider network is limited to a local area.

• Referrals not required – Members can still see in-network specialists without a PCP referral, despite the local network.

• No out-of-area coverage – LPPO plans only cover non-emergency care within the local service area. No nationwide coverage.

LPPOs offer localized PPO networks as a potentially lower cost option for members who don’t need nationwide coverage. The network is limited to a region you live or work in.

What is an RPPO?

RPPO stands for Regional Preferred Provider Organization. Here are some key characteristics:

• Regional network – RPPOs contract with a network of providers within a multi-state region such as the Midwest, Southwest or Mid-Atlantic.

• In and out-of-region care – You have coverage when using providers within the RPPO’s region but can also access care outside the region.

• Lower costs in-region – You pay less for in-network care when you see providers within the RPPO’s regional service area.

• Higher costs out-of-region – Out-of-network rates apply when seeing providers outside the RPPO’s contracted region.

• No referrals – You don’t need a PCP referral for regional network specialists.

RPPOs offer a middle ground between local and nationwide plans. You get a discounted regional network but aren’t limited to only in-network care.

Comparing LPPOs vs RPPOs

Here is how LPPO and RPPO plans stack up:

Pros and Cons of LPPO and RPPO Plans

LPPO Pros

• Low premium costs
• No need to change local providers
• Keep seeing preferred local specialists
• Don’t pay for nationwide coverage you may not use

LPPO Cons

• Very limited coverage area
• No out-of-area coverage except emergencies
• Disruption if you move from service area
• Any non-emergency care out of area means high out-of-network cost

RPPO Pros

• Access to regional and nationwide providers
• Lower costs when using regional providers
• No referrals required
• No disruption when moving within broader region

RPPO Cons

• Higher premiums than LPPOs
• You may pay for coverage areas you won’t use
• Higher out-of-pocket costs when going out-of-network

LPPOs meet localized needs while RPPOs bring flexibility through a wider provider network. Evaluate premium costs and provider access when choosing what works for your location and budget.

Who is eligible for LPPO and RPPO plans?

Here is an overview of LPPO and RPPO eligibility:

• Individuals/families – Those without employer coverage can purchase LPPO or RPPO plans directly through public insurance exchanges or insurers.

• Employer groups – Companies commonly offer group LPPO and RPPO plans to employees as benefits options.

• Medicare Advantage – LPPO and RPPO plans can provide Medicare Advantage coverage for people with Medicare.

Certain individual LPPO and RPPO plans may limit eligibility based on criteria like county/state of residence, age, income level, or health status. Employer and Medicare plans also have program-specific eligibility rules.

How do you find LPPO and RPPO providers?

Here are some tips for finding LPPO and RPPO network providers:

• Provider search tools – Insurers provide online provider search tools where you can search for doctors by specialty, location, hospital affiliations and other criteria.

• Hard copy directories – Many LPPOs and RPPOs publish printed provider directories that list all in-network practitioners and facilities.

• Customer service – You can call the insurance company’s customer service line and ask for help locating in-network providers in your county or region.

• Network name – Knowing the specific network name for your LPPO or RPPO plan helps identify participating providers. For example, “Are you in the XYZ Regional Preferred network?”

• Provider office contacts – When scheduling appointments, you can ask if a provider participates in your specific LPPO or RPPO network before booking.

Checking provider network participation is key to maximizing LPPO and RPPO benefits and cost savings.