PPO plans are usually better if you have a lot of regular office visits and lab tests, and take regular medications but otherwise don't expect to spend much beyond the deductible listed on the high-deductible plan.
HMO plans might involve more bureaucracy and can limit doctors' ability to practice medicine as they see fit due to stricter guidelines on treatment protocols. So just as with patients, providers who prefer a greater degree of flexibility tend to prefer PPO plans.
With PPO insurance, you'll pay less out of pocket when you get care within that network. You can still see an out-of-network provider, but you'll get the most coverage when you stay within the PPO network. PPO health plans may be a good fit for someone who lives in 2 different states or travels often within the U.S.
With a PPO, you do not need to maintain a primary care physician and can see a different doctor of your choice at any time, including specialists. This also means when you are traveling, you can receive care wherever you are. Additionally, PPO plans offer more options for laboratory service providers.
Choose a PPO plan if:
You have health problems, visit the doctor frequently, or take many medications. You are expecting a major medical expense such as surgery or the birth of a child. You're willing to pay higher premiums in exchange for the certainty of lower out-of-pocket costs related to specific medical needs.
The deductible is a specified annual dollar amount you must pay for covered medical services before the plan begins to pay benefits. PPO deductibles are based on a percentage of your effective salary, as shown on the PPO Deductibles and Medical Out-of-Pocket Maximums chart.
Because PPOs offer access to a larger provider network, your monthly costs may be higher.
Out-of-pocket costs may be higher with PPO plans
Out-of-pocket costs are expenses you pay in addition to premiums, such as copayments and deductibles. PPO plans typically have higher out-of-pocket costs and may have higher deductibles.
HMO plans typically have lower monthly premiums. You can also expect to pay less out of pocket. PPOs tend to have higher monthly premiums in exchange for the flexibility to use providers both in and out of network without a referral. Out-of-pocket medical costs can also run higher with a PPO plan.
But, PPO plans frequently enable more freedom in selecting specialists and could have wider provider networks. However, PPO plans could also have more excellent patient out-of-pocket expenses, making them less appealing to some doctors.
PPO participants are free to use the services of any provider within their network. They are encouraged, but not required, to name a primary care physician, and don't need referrals to visit a specialist. Subscribers may go out of network for coverage but it often comes at a higher cost.
A Preferred Provider Organization (PPO) Plan is a Medicare Advantage Plan that has a network of doctors, specialists, hospitals, and other health care providers you can use. Can I get my health care from any doctor, other health care provider, or hospital? Yes.
PPOs Usually Win on Choice and Flexibility
Unlike most HMO health plans, you won't likely need to select a primary care physician, and you won't usually need a referral from that physician to see a specialist.
Preferred provider organizations (PPOs) represent a form of managed care in which providers agree to accept discounted fees in exchange for the expectation that their patient volume will increase or at least be maintained.
One of the biggest advantages of PPO policies is their flexibility. Given that PPO plans offer a larger network of doctors and hospitals, you have a lot of say in where and from whom you get your care. Any doctor and healthcare facility within your insurance company's network offers the same in-network price.
If your health plan covers medications, it is possible your prescription expenses go toward a general deductible. If your plan has a separate deductible for prescriptions, these expenses will count toward this instead and will not affect your medical costs deductible.
HDHPs can be a good form of insurance for the young and healthy — especially if your employer offers you HSA contributions. But for anyone with significant medical expenses, an upcoming surgery, or a serious health condition, a PPO could be a better fit because of the lower deductible.
For example, if your health insurance plan's allowed amount for an office visit is $100 and your. coinsurance is 20%: • If you've paid your deductible: you pay 20% of $100, or $20. The insurance company pays the rest.
The HDHP may work best for a young, healthy, and lucky person who has no medical conditions that require regular care and extra money to save in an HSA. An individual or family that wants to avoid big bills at unexpected intervals might prefer a PPO.
How much does a PPO plan cost? Because PPO plans provide the most flexibility for the person insured, most individuals will find that PPOs have the most expensive monthly premiums. The average monthly cost of a PPO health insurance plan for a 40-year-old is $576, which is 20% more expensive than an HMO policy.