PPO Health Insurance Plans Review: how it works

Updated: November 9, 2022
ppo health insurance

A preferred provider organization (PPO health insurance) is a well-liked health insurance option for both individuals and families. PPOs involve networks of health insurance providers and contracted medical personnel. Preferred providers are hospitals and doctors who offer services to the insurer’s plan policyholders at discounted prices. Participants in the plan are granted coverage for out-of-network healthcare providers in addition to receiving the maximum PPO benefit when they see in-network healthcare providers.

The Functioning of Preferred Provider Organizations (PPOs)

A preferred provider organization or PPO is a managed-care network of medical specialists and facilities, including hospitals, primary and specialty care physicians, and other healthcare professionals, who work under a contract with insurance companies to provide services to participants who have subscribed. These are customers or plan participants protected by the insurer’s health plan.

Healthcare providers and facilities negotiate service rates and timetables with plans. As a result, the agreed-upon rate is frequently less than their standard fees. Insurance companies pay the PPO a fee to use the provider network in exchange for lower rates.

Participants in PPOs are free to use any provider’s services in their network. They don’t need the recommendation to see a specialist, and a primary care physician is advised but not required. Although subscribers may travel outside of their network for coverage, the fee is frequently higher. The following explores further cost information.

PPO plan attributes

Choose to receive treatment from a provider (such as a doctor, hospital, clinic, or pharmacy) outside of the network. You’ll be responsible for paying a high premium and submitting your own claims for those out-of-network services. There will be an additional out-of-network deductible that you must meet. The PPO plan covers global emergency and urgent care coverage 24 hours a day, 7 days a week. However, eligible emergency treatment is always covered, even out-of-network.

PPOs have a variety of expenditures, as mentioned above, and premiums are typically greater than those of conventional insurance plans. PPO plans typically have higher premiums since managing and administering them is more expensive. Copayments are often the participant’s responsibility; they pay it directly to the provider at each visit. Patients must also fulfill deductibles before the policies begin to take effect and begin paying claims in full.

As previously mentioned, participants in plans are also permitted to use out-of-network facilities, usually at a higher rate. A fair and typical fee schedule determines these fees. In some cases, coverage may not apply, or, more frequently, the excess charge is charged to the consumer if the claims submitted by these healthcare providers are higher than the reasonable and customary costs for the services provided.

The degree of flexibility connected to PPOs’ higher cost is one thing to keep in mind. Compared to other products on the market, these plans provide more alternatives. PPO networks frequently have several providers and are spread across numerous cities and states. Participants gain by selecting a provider or using one in an emergency.

Health Maintenance Organization (HMO) vs. Preferred Provider Organization (PPO)

Health maintenance organization (HMO) plans, in contrast to PPOs, mandate that participants obtain healthcare from a designated provider. This primary care physician coordinates the insured person’s care. Both schemes permit the insured to seek out specialist care, but a referral to a specialist from the designated primary care physician is necessary under an HMO plan.

For the convenience, accessibility, and freedom they provide, PPO plans demand greater premiums than nearly every other type of plan, as was already said. A greater selection of hospitals and physicians is part of this. Higher premiums are charged for the plans with the lowest/fewest out-of-pocket costs, such as those with low deductibles and copayments. Due to the insurer bearing more of the associated costs, the premium price has increased. Alternatives with lower premiums, on the other hand, result in higher out-of-pocket expenses for the insured and reduced expenses for the insurer.

PPO plans offer more extensive coverage, covering a variety of treatments that other managed-care plans might not cover or for which they would impose an additional fee.

PPO plans have always been the pick of participants in workplace groups. Participants today, however, demand more choices for managed healthcare. As a result, many employers also provide HMO plans. Although services and freedoms normally associated with PPO plans are frequently restricted, some participants prefer HMO plans for their affordability because HMO premiums are less expensive.

The Function of PPO Deductibles

The deductible on your health insurance policy is the annual monetary amount that you are liable for paying out of pocket before your policy begins to give benefits. There could be two distinct annual deductibles with PPO plans. One is for PPO network providers, while the other—typically a greater amount—is for providers outside the network. The latter is more expensive because the PPO wants to tempt you to continue utilizing its favored providers and remain in the network.

What are PPOs’ benefits and drawbacks?

Prior to the advent of health management organizations (HMOs) and exclusive provider organizations (EPOs), PPOs were the most prevalent form of health insurance. Significantly more than half of all employees participate in one. Listed below are the advantages and disadvantages of this type of strategy.

What advantages do PPOs provide?

  • More adaptability: PPOs, unlike HMOs, do not need you to choose a primary care provider (PCP). In addition, PPOs pay a percentage of the cost of out-of-network care, allowing you to choose from a larger pool of medical specialists.
  • No references are necessary: PPOs don’t require PCPs. Since no physician will direct your care, you will not need to convince anyone to refer you to other medical professionals.
  • May offer other treatments: Some PPOs provide participants with a broader selection of services, including chiropractic and acupuncture services, in addition to basic examinations and preventative care. These particulars vary depending on your plan.
  • Stay with you: PPO coverage protects you even while you are away from home, as you are not restricted to a certain network of healthcare providers. Your coverage remains in force when you travel or need to see doctors and specialists outside of your state. In contrast, HMOs typically limit you to a network in your nearby area.

What are the disadvantages of PPOs?

  • Flexibility is not free: PPO rates are often higher than those of other plan types. In 2021, annual PPO plan premiums for single employees were $1,389, and for families, they were $6,428, according to the Kaiser Family Foundation (KFF). In contrast, HMO rates are $5,254 for families and $1,204 for individuals.
  • Greater likelihood of having an annual deductible: According to KFF data, only 15% of PPO employees and 43% of HMO personnel lack deductibles. (The average yearly deductible for HMOs and PPOs for employees whose plans contain a general deductible is comparable: $1,271 for HMOs and $1,245 for PPOs.)
  • PPO members can see any doctor or specialist, but there are distinct cost-sharing standards to consider. If you attend a non-network doctor, you will likely be required to pay a higher coinsurance percentage. For instance, your copay maybe 20% for a physician within the network and 40% for a physician outside the network.
  • Submit a claim: If you leave your PPO network, your insurance company may require you to submit a claim form. If you frequently visit non-network providers, filling out and submitting paperwork may become laborious and time-consuming.
  • Responsible for care coordination: Choosing your medical experts directly places the responsibility for managing your care in your hands. In contrast, HMOs and other insurance plans appoint your PCP as the primary care coordinator and manager.

The operation of a PPO deductible

The amount you must pay out-of-pocket for covered procedures before your insurance begins to pay anything is known as a deductible.

For instance: Let’s say your annual deductible is $1,200. Your doctor will submit an insurance claim after visiting you. Your deductible will subsequently be increased with the credit for the visitor’s fee. According to the terms of your policy documentation, once you’ve paid a total of $1,200 for medical expenses, your insurer will cover subsequent expenses for the remainder of the year.

However, if you have a PPO, you can have more than one deductible to pay. You can have two deductibles: one for services within your network and one for services outside of it. The deductible is usually higher for services received outside of a network. To learn the requirements of your plan contract, read the small print.

Can I have both an HSA and a PPO?

Yes. Certain PPOs are configured as high-deductible health insurance plans (HDHPs). You are permitted to enroll in a health savings account (HSA) in addition to a PPO that is also a qualifying HDHP. An HSA is unique savings account for pretax money that you can utilize to cover future out-of-pocket healthcare costs.

But some guidelines do apply. You will have to pay a hefty deductible before your provider covers charges, even though you are enrolled in a PPO. For individuals and families, the minimum deductibles for qualified HDHPs in 2022 must be $1,400 and $2,800, respectively. They cannot go over either $7,050 or $14,100.

You can also check Well Care health insurance reviews to find your options.

What distinguishes a PPO from other types of networks?

All varieties of health insurance policies cover services. The primary distinction will be in the locations where you can access such medical treatments, which will depend on the health insurance plan’s provider network.

Different networks will also affect how much you pay for certain health services in addition to where you receive care. This makes it crucial to pick a health insurance plan with the appropriate network for your requirements. Below, we have provided thorough explanations of each provider network in comparison to a PPO.

PPO versus HMO

You must select a primary care physician (PCP) to oversee your care if you have an HMO health insurance plan. This is the key distinction between an HMO and a PPO. In this situation, you will also need a recommendation from that PCP before seeing any specialists, and you’ll probably have to pay full price for any out-of-network medical treatments.

Since there are more limitations on where you can get care with an HMO than a PPO, the premium will be a little less expensive.

PPO versus EPO

In contrast to PPOs, exclusive provider organizations (EPOs) have the strongest restrictions on the hospitals and doctors you can see. In fact, unless you require emergency treatment, you can only see in-network doctors with an EPO. Given these limitations, you should make sure that the in-network physicians in your area accept the policy before choosing an EPO health insurance plan.


PPOs and point of service (POS) insurance only differ in the degree of flexibility they provide. Both kinds of networks offer discounted fees for in-network visits and significantly lower rates for out-of-network visits to specialists. With a POS plan, however, you will have to choose a PCP who will have to make referrals for you to see specialists.

Top Health Insurance Providers in 2023

There is a Blue Cross for All of Us. When it comes to health insurance, Blue Shield is among the top choices. The best value plans may be found at Oscar. Bright Health is great for dental coverage. Kaiser Permanente has the highest-quality plans.

Aetna CVS Health Clinic; United Healthcare Has the Best Medicare Advantage Plans.

A PPO health insurance plan is best for whom?

For people who prefer the freedom to visit any doctor and hospital and see specialists without a reference, PPO insurance plans can be a viable option. A PPO may be the best option if you choose to oversee your own medical treatment without the guidance of a primary care physician.

It’s crucial to consider the price when determining whether a PPO plan is the best option for you. PPO plans have substantially higher premiums since they provide such extensive flexibility. A PPO plan is most likely not the best choice for you if you are looking for the most economical health insurance option with low out-of-pocket expenses.


What distinguishes health insurance plans from PPOs and EPOs?

A PPO provides more freedom with restricted out-of-network provider coverage or reimbursement. A more constrictive EPO offers less out-of-network provider coverage or compensation. EPO costs are often less than PPO costs for members who are on a tight budget.

PPO deductible: What is it?

Before the insurance plan starts to pay benefits, you must meet the deductible, which is a set yearly monetary amount for covered medical procedures. According to the PPO Deductibles and Medical Out-of-Pocket Maximums chart, PPO deductibles are calculated as a percentage of your effective pay.

Is PPO deductible high?

PPOs typically have lower deductibles than HDHPs but higher premiums than HDHPs. A health savings account, or HSA, cannot be opened with a traditional PPO.

In-network care, is it covered by a PPO?

PPO plans do cover out-of-network treatment, but they sometimes don’t provide as much assistance as if you receive in-network care. The terms of your plan will determine how much you will be responsible for paying for out-of-network care. However, when you visit a physician who is part of the PPO’s network, you often pay less.

Do you still require a primary care physician if you have a PPO?

If you have a PPO, you are not obligated to see a primary care physician. You are not required to visit or speak with your primary care physician before managing your own care and seeing any doctor you want.

However, if you currently have a working connection with a primary care physician, you can carry on doing so. Their services will be covered to the fullest extent if they work with the PPO’s network.

Does seeing a specialist under a PPO require a referral?

No, a reference from a primary care physician is not necessary with PPO insurance to see a specialist. The process of receiving specialized care may be sped up as a result.

To get the greatest coverage from your insurance provider, if you’re picking a specialist on your own, make sure to look for experts who are in your PPO’s network.

Visit our website NewHealthinsurance.com to learn more.

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