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PPO Health Plans

Preferred Provider Organization Plans — PPO Plans, Coverage, & Quotes

What is PPO insurance? That is a question many have been asking themselves. The PPO health plan is an increasingly common type of managed care health insurance. Such plans consist of a a group of providers. These groups include doctors, hospitals, and even medical labs. PPO plans are more flexible than HMOs, but there are some similarities: a nearly unlimited amount of health care services are covered, in exchange for a monthly premium. In addition, PPO health insurance plans normally include an annual deductible. This deductible represents the amount you must pay out-of-pocket before medical coverage kicks in. Co-payments ranging from $10 to $30 per service count towards it.

A PPO health insurance plan allows you to see any doctor of your choice, allowing you more control. Visits are most affordable if you stay within the network of physicians that work with your PPO medical plan. PPO plans are able to offer services at a reduced rate because of the increased patient volume brought by the network, meaning that you will only owe a small co-pay. Unlike other types  of managed care, you will still receive partial reimbursement if you choose an out-of-network doctor. You will have to shoulder more of the cost than you would if you saw an in-network physician, and you may be required to file claims yourself in order for PPO plans to pay part of the bill.

PPO health plans are unique because they allow patients to practice “self-referral”. This means that you can see any specialist you want, without waiting for your primary care physician (PCP) to refer you. You can instead make an appointment yourself. If the specialist is also in-network, the PPO plan will cover it at their standard rate. Self-referral can save you time and money, because you do not have to visit your primary care doctor and pay a co-payment. If you see a specialist outside of the PPO insurance plan’s preferred network, it will be more costly; PPO plans may cover 80% of the cost to see an in-network physician, but just 50% of the cost to see one who is out-of-network. Doing so could be helpful for someone with a rare condition requiring special treatment from specialists unlikely to be covered in a PPO health plan. However, in most circumstances you should make sure the physicians of your choice are in the PPO network.  Comparing PPO plans is important, since some PPO insurance plans have more extensive networks than others.

Although it is recommended that you have a primary care physician, PPO health insurance plans do not require you to select one. A PPO health plan doesn’t put a gatekeeper in charge of your health care, which has great appeal. There is somewhat of a trade-off, though: what you gain in freedom, you partially lose in value and cost. Increased flexibility means that PPO plan premiums are usually higher than those of HMOs or other forms of managed care. There are ways to reduce PPO health insurance premiums, such as by having a higher deductible. It is important to balance the expense of monthly premiums with the annual deductible.

There are also higher out-of-pocket expenses, in the form of co-payments and co-insurance percentages. You must also be careful to know if your policy is one of the PPO plans that only covers a  specified percentage of “reasonable costs” for medical treatment. Beyond that co-insurance percentage, you may be responsible for the remaining bill if you choose an out-of-network physician or hospital that your health insurance company considers too expensive.

VitalOne’s licensed insurance agents can help you decide if a PPO health plan is right for you. We can provide you with quotes and coverage comparisons for multiple PPO plans.

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