My Coverage Explained

Top 5 Q&A's to Understanding a PPO

Understanding your options in health insurance can be confusing. There are many choices, and it can be hard to know the best health plan for you and your budget. While many Americans get health insurance through their employers, others are looking for their health care coverage through the Health Insurance Marketplace. If you are part of an employer’s group plan, Preferred Provider Organizations (PPOs) are often on the menu of health insurance options. While both PPOs and other health insurance plans offer savings, they have very different levels of coverage and costs to consider when choosing a method of coverage that’s right for you. Here are some questions and answers about PPOs to help you decide.

  1. What is a PPO?
    A PPO is a managed care network of doctors, hospitals and other providers like dentists and eye doctors who contract with insurance companies to offer services at a more affordable cost to the patient. When you see a doctor or go to a hospital within your network, you will get the lower price that your health insurance company negotiated with the provider. You can still use a doctor out of your network, but it will be at a higher price.

  2. How do I choose between a PPO and other health plans?
    Most people have access to PPOs through their employers, but not everyone. If you can’t choose a PPO insurance plan, then a Health Maintenance Organization (HMO), High Deductible Health Plan (HDHP) or Consumer-Driven Health Plan (CDHP) may be right for you. If you can buy a PPO and have expected, high medical expenses, then a PPO might be right for you. If you rarely go to the doctor and have no health concerns, then you may decide to buy a plan with lower monthly premium payments. Consider your current circumstances and carefully review all of your options before making your final decisions, so you can save the most money with your plan of choice. You can always consult with your health insurance broker or your Human Resources department to help you decide.

  3. What do I get with a PPO Plan?
    Good news! You get access to a broad network of doctors, hospitals and other providers at a negotiated rate. With a PPO, you have a flat copay fee for things like doctor and hospital visits. Typically, you don’t have to meet a deductible before your plan starts paying your benefits; however, there are some plans (including some Bronze level PPOs) that DO require you to meet a deductible; and once you meet it, you pay a percentage of the cost (called a cost share) for covered services, except preventive services, which are covered at no cost to you when you see a doctor in your network.

    With a PPO plan, you save money when you use doctors, hospitals and other providers that are in your network. Once you’ve hit your out-of-pocket maximum, your health plan pays qualified medical expenses set by the Internal Revenue Service (IRS) at 100 percent. If you are dealing with ongoing medical conditions, or need to plan for upcoming medical expenses like having an operation, a PPO plan may be right for you. With a PPO you also must consider having higher monthly premiums in addition to having copays for tests and doctor’s appointments. You also have more coverage and pay less when it comes to paying at the time of your doctor visit or when having bigger medical events like hospital stays, surgeries and expensive medical tests.

    Here’s a chart to help you see what you get:
  4. What is not part of a PPO?
    Unfortunately, not all doctors accept every PPO health plan. That’s why it is important to use tools like the Blue Cross and Blue Shield of Illinois Provider Finder® to make sure your doctor or hospital is in your PPO insurance plan’s network.

  5. What are the differences between a PPO and other health plans?
    Your monthly premium (amount you pay for the plan each month) can be higher in a PPO than with other health insurance plans. Your health insurance company pays a portion of your doctor visit with a PPO. You can also help pay your medical bill with a Flexible Spending Account.

PPOs are very different from other health insurance plans, and we want you to choose the best health insurance plan for your needs.

Have questions about health insurance plans? Ask in the comments!

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