Is PPO Insurance Right for You?

PPO stands for preferred provider organization and is a healthcare insurance plan that allows members to seek medical care from doctors, hospitals and other healthcare facilities outside of their plan’s network. Also, primary care physicians (PCP) are not required nor are referrals to see a specialist. Due to this flexibility, PPOs are the most expensive type of healthcare plan.

Continue reading to see how you can get a PPO plan and how it compares to a health maintenance organization (HMO), exclusive provider organization (EPO) and a point of service (POS) plan.

On This Page

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  How Does PPO Insurance Work?

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  Is PPO Insurance Right for Me?

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  How Much Is PPO Insurance?

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  What's the Difference Between PPO, HMO, EPO and POS?

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  How To Get a PPO Insurance Plan

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  FAQs

How Does PPO Insurance Work?

PPO plans have a network of providers that are contracted with your health insurance, allowing you to seek services for minimal cost depending on your copay and deductible. PPO plans will still cover you when you seek medical care outside of your plan’s network but your out-of-pocket costs will be higher.

If you get medical care from an out-of-network provider, you’ll submit a claim to your insurance company, usually through a mobile app, online portal or over the phone, and your insurance company will reimburse some of the cost. This flexibility allows those who have PPOs to get coverage anywhere and by anyone.

A bonus for PPO plans is that policyholders are not required to have a primary care physician or obtain a referral before seeing a specialist.

PPO Rules for Subscribers

Those who have a PPO plan enjoy wider access to medical care with fewer restrictions. PPO subscribers can receive medical care from out-of-network providers at the cost of higher out-of-pocket expenses than they would face with an in-network provider. Additionally, PPO subscribers can see a specialist without having to obtain a referral and there is no need for policyholders to have a PCP.

Primary Care Physician (PCP)

Primary care physicians are not required when you have a PPO insurance plan. Keep in mind, having a PCP may still be worth having as you will have someone who, over time, comes to understand your medical needs and history and can act as a quarterback when it comes to coordinating your care.

Additionally, you won’t need to get a referral from a primary care physician in order to get treatment from a specialist. Instead, you can make an appointment on your own.

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Is PPO Insurance Right for Me?

Whether a PPO plan is right will depend on your life situation.

PPOs are attractive to people who want greater control over their healthcare. There is no requirement for a PCP and no need to get a referral to see a specialist.

PPOs are useful for people who frequently travel. PPO members can still enjoy some coverage if they see an out-of-network provider in a different state. Other plans will only cover out-of-network care if it is a medical emergency.

How Much Is PPO Insurance?

Actual costs for a PPO plan will vary by person and will consider several pricing factors, such as:

• Age
• Deductible
• Health history
• Health plan
• State

Like most healthcare plan types, PPO insurance is sold in five tiers: bronze, silver, gold, platinum and catastrophic. The amount you pay for coverage will depend on which tier you choose. Bronze-tier health plans will have the lowest monthly payments and higher out-of-pocket costs while the platinum tier charges some of the highest monthly premiums but your out-of-pocket costs are much lower.  These tiers do not measure the quality of care offered.

A PPO health plan is more expensive than the other insurance types because of its flexibility and often carries a larger provider network.

What's the Difference Between PPO, HMO, EPO and POS?

A PPO is one of several coverage options available by health insurance companies. Each coverage type dictates how coverage works with in- and out-of-network providers, if you need a PCP or if a referral is required for a specialist. Below, we compare PPOs to HMOs, EPOs and POS’.

PPO vs. HMO

PPO plans do not require members to have a primary care physician while HMOs do. Also, PPOs allow members to get care from out-of-network providers, while HMOs will only cover out-of-network care in only emergency situations. PPO networks are also often larger than HMO networks.

PPOs cost more than HMOs due to the PPO’s flexibility and network size.

PPO vs. EPO

PPO health insurance plans offer greater flexibility with seeing an in- or out-of-network provider. PPO allows policyholders to seek medical services outside the network — you will still bear some out-of-pocket costs but your insurer will provide some coverage. In contrast, an EPO will not provide health insurance coverage for out-of-network care unless it is an emergency. This added flexibility helps explain why PPOs typically cost more than EPOs.

Neither EPOs nor PPO plans require policyholders to obtain a referral before they can see a specialist. You are also not required to have a PCP.

PPO vs. POS

PPO and POS plans allow policyholders to seek treatment out-of-network at a higher out-of-pocket cost. While a PPO doesn’t require you to get a referral before seeing a specialist, this requirement will apply to a POS plan.

How To Get a PPO Insurance Plan

You can purchase a PPO policy when it’s time to enroll in a health insurance plan. Every health plan will state if it’s a PPO, EPO, HMO or POS. Find the plan that fits your needs while not draining your bank account, and you’re done.

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SmartFinancial can help you find the plan you need for the price you want. Enter your zip code below or call 855.214.2291 to receive your free health insurance quotes.