PPO Features
Preferred Provider Organization (PPO) plans offer the flexibility to see any doctor or specialist without referrals. Enjoy lower costs with in-network providers while maintaining the freedom to go out-of-network when needed.
Preferred Provider Organization (PPO) plans offer the flexibility to see any doctor or specialist without referrals. Enjoy lower costs with in-network providers while maintaining the freedom to go out-of-network when needed.
Preferred Provider Organization (PPO) plans are consistently among the most popular health insurance options because they strike an ideal balance between cost savings and flexibility. Unlike more restrictive plan types, PPOs give you the freedom to see any healthcare provider you choose, including specialists, without requiring referrals or gatekeeper approval.
The PPO structure offers a financial incentive to use in-network providers through lower copays, deductibles, and coinsurance, but it doesn't lock you into the network. If you have a specialist you trust who isn't in-network, or if you need care while traveling, or if the best provider for a complex condition happens to be out-of-network, you still have coverage. This flexibility is invaluable for many healthcare consumers.
Our PPO plans feature extensive provider networks and straightforward benefits that put you in control of your healthcare decisions. You choose your doctors, you decide when to see specialists, and you maintain the option to go outside the network when it makes sense for your care.
See specialists directly without getting permission or a referral from your primary care doctor. Schedule appointments with cardiologists, dermatologists, orthopedists, or any specialist whenever you determine you need that care.
Freedom to see any licensed provider, even those outside the network. While you'll pay more for out-of-network care, having this option ensures you're never without coverage when you need to see a specific provider.
Significant savings when you use preferred providers who have agreed to negotiated rates. In-network care means lower copays, lower coinsurance percentages, and costs that count toward a lower out-of-pocket maximum.
Access to thousands of doctors, hospitals, specialists, urgent care centers, pharmacies, and ancillary providers across the country. Our networks include most major healthcare systems and community providers.
Choose any in-network doctor as your primary care provider and change providers at any time without restrictions. No need to select a primary doctor if you prefer to manage your own care across multiple providers.
National network coverage means you can find in-network providers when traveling, relocating, or maintaining residences in multiple locations. Emergencies are covered at in-network rates regardless of where they occur.
HMO (Health Maintenance Organization) plans typically have lower premiums but require you to choose a primary care physician who coordinates all your care, get referrals for specialists, and stay within the network (except emergencies). PPOs offer more flexibility at a higher premium.
EPO (Exclusive Provider Organization) plans work like PPOs with no referral requirements, but they don't cover out-of-network care except for emergencies. PPOs cost more but provide the safety net of out-of-network coverage when you need it.
POS (Point of Service) plans combine HMO and PPO features: you choose a PCP who provides referrals, but you can go out-of-network at higher cost. PPOs don't require a PCP or referrals, offering simpler, more direct access to care.
High Deductible Health Plans (HDHPs) can be structured as PPOs or other plan types. The key difference is the higher deductible and HSA eligibility. A PPO-style HDHP gives you PPO flexibility with the tax advantages of a Health Savings Account.
Understanding how PPO cost-sharing works helps you make the most of your benefits and manage healthcare expenses:
PPO plans have separate benefit levels for in-network and out-of-network care. In-network benefits feature lower deductibles, copays, and coinsurance. Out-of-network benefits have higher cost-sharing and a separate (usually higher) out-of-pocket maximum.
When you use in-network providers, you benefit from negotiated rates. You might pay a $30 copay for a doctor visit, 20% coinsurance for procedures after meeting your deductible, and costs count toward your in-network out-of-pocket maximum.
Out-of-network providers can charge whatever they want (no negotiated rates). You'll typically pay a separate, higher deductible, then 40-50% coinsurance. You may also be responsible for any amount above the plan's "allowed amount" for services.
The No Surprises Act protects you from surprise bills when you receive emergency care or when out-of-network providers treat you at in-network facilities without your advance consent. Understanding these protections helps you navigate complex billing situations.
No, PPO plans don't require you to select or register a primary care physician. However, having a PCP is recommended for coordinated care, preventive services, and having a doctor who knows your medical history. You just don't need permission from a PCP to see specialists.
Out-of-network costs vary by plan but typically include a higher deductible (often double the in-network amount), higher coinsurance (40-50% vs. 20%), a higher out-of-pocket maximum, and potential balance billing for amounts above allowed charges. The total can be significantly more than in-network care.
Going out-of-network may make sense when: you need a specialist with unique expertise not available in-network, you're seeking a second opinion from a renowned expert, you're traveling and need non-emergency care, or the out-of-network provider offers significantly better quality for a complex procedure.
Yes, PPO premiums are typically 10-20% higher than comparable HMO plans because of the greater flexibility and out-of-network coverage. However, many people find the flexibility worth the additional cost, especially those who want choice in providers or anticipate needing out-of-network care.
Yes, under the ACA, preventive care is covered at 100% with no cost-sharing when you use in-network providers, regardless of plan type. This includes annual checkups, immunizations, screenings, and other preventive services. Out-of-network preventive care is not guaranteed to be free.
If you value the freedom to choose your own doctors and specialists without restrictions, a PPO plan provides the flexibility you need. Speak with a licensed agent today to find a PPO plan that balances comprehensive coverage with affordable premiums.