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What is PPO Insurance and How to Choose the Right PPO Plan


Preferred Provider Organization (PPO) is a managed fee for service health care plan option. The network is comprised of approved contracted medical providers. Like most health plans, PPOs recommend annual check-ups, obstetrician and gynecologist and pediatrics as preventatives for maintaining good health.

The cost of services or coverages varies depending on the plan selected. One distinction of PPOs is the ability to choose a personal doctor as your primary care physician without a referral. Members can select a team of healthcare providers a family doctor for general healthcare internal medicine physician specialists in the fields of cardiologist, gynecologist or ears, nose or throat (ENT).

Choosing the Right PPO Plan

When choosing a PPO plan look for good quality of service from both the insurer and the provider. Illness requires attention, so make sure you receive care right away. You have the right to ask questions about the services and the medical decisions made on your behalf.

Most providers will give you information on the services delivered. Included in the material are the service limits and coverage rules that apply. Read the information, it can help you avoid getting a bill for services you thought were paid by the insurance plan.

It’s impossible to predict your health throughout the year. However, you can estimate the medical services you need for the year. Carefully review and compare the plan's program costs and features based on your healthcare demands.

Understand the Cost of Healthcare

All PPOs charge members a monthly fee (premium). Depending on the level of medical services and the size of the family costs will vary. Plans offer different savings methods for medical services associated with the cost of coverage. It’s important to understand your health and your family’s health needs when choosing a plan. 

If you are considering a change, talk to the plan’s administrator, they can tell you if your doctor practices under the new program. Doctors have agreements with more than one PPO, making it possible to change health plans without changing doctors.

It’s rare, but there are cases where the doctor may not be part of the PPO plan. You can continue seeing the doctor, but the shared cost between the PPO plan and your out-of-pocket could change drastically. Another situation affecting the shared price; receiving health care services while traveling internationally or outside of the local region.

Maximizing Your Health Benefits

Employers and employees generally share the premium cost; shared premium fees are deducted from the employee’s paycheck. Self-employed individuals can purchase PPO insurance directly; paying the entire premium cost.

Besides paying the monthly premium PPO individuals or families have deductibles. This is the amount you have to spend before the insurance pays for services under the plan. When choosing a plan consider the yearly expenses, deductibles and premium costs. Company provided health care plans offer options for raising or lower deductibles to adjust the premiums. 

  • Copayments help to cover the cost of visits; the plan may include a copay payment each time healthcare services are delivered.
  • Out-of-pocket costs could consist of prescriptions, lab tests or specific examinations.

The insurance plan will pay 100 percent for covered services once members reach the plan’s maximum deduction amount. For some members this is an excellent time to catch up on neglected doctor visits due to busy schedules or limited budgets.

Take the time to evaluate the total cost of the plan including the monthly premium, annual deductions and unique expenses to meet your health care needs and your budget. Talk with your insurer about the cost and savings programs without sacrificing the quality of medical services. Keep in mind if the doctor or the hospital is not part of the PPO, be prepared to pay for the services.

This content is developed from sources believed to be providing accurate information, and provided by Twenty Over Ten. It may not be used for the purpose of avoiding any federal tax penalties. Please consult legal or tax professionals for specific information regarding your individual situation. The opinions expressed and material provided are for general information, and should not be considered a solicitation for the purchase or sale of any security.


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