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What is PPO Plan – Do You Need Preferred Provider Organization (PPO)

For individuals who were never sold on the idea of buying health insurance plans, the ongoing pandemic possibly has presented the strongest case for the same. The immense amount of pressure on the healthcare structure combined with the expensive treatment is never a good sign for your savings. Having a good health plan in such times can be a big boon. And PPO is one great example of the same.

If you are looking for a health plan either for an individual or a family, the chances are high that you will come across PPO as a recommended option. This begs a more fundamental question, what is PPO? And should you opt for one? We will cover all that you need to know.

What is PPO Plan?

PPO or Preferred Provider Organization is a popular health plan that you can opt for either yourself or your family. Inherently, the plan offers a large and extensive list of providers and hospitals to choose from. You can choose to visit any physician or provider within your network without ever having to worry about a referral from your primary care physician.

While a PPO is majorly beneficial if you are looking for a physician within your network, the plan also offers coverage for providers that are out of the network. Ensuring that you do not feel stuck with in-network physicians in some cases.

Important Things to Know about PPO Plans

Before you opt for PPO plans, here are some crucial bits of information that you ought to know.

  1. PPO plans include urgent care coverage and global emergency, round the clock and all through the week.
  2. Choosing a primary care provider will help you coordinate your health care and become a health advocate for you. However, it is not mandatory to choose one.
  3. You can opt for medical care outside of your network, be it a hospital, physician, pharmacy or clinic. You will end up paying higher costs for these out of the network services and more importantly, you will have to file for the claims yourself. Yet, emergency care that is eligible is covered as a part of the plan, even for out of the network scenario.


Workings of PPO

A PPO is known to be a strong network of medical professions as well as facilities. These facilities include hospitals, speciality physicians, primary physicians, and other types of healthcare professionals. There is usually a contract between these professionals and insurance providers, where the medical professionals provide services to individuals who are participants.

As a consumer or user of PPO plans, you will receive encouragement to opt for any of the physicians or hospitals within the network of the insurance provider. And more importantly, you do not have to choose a primary care physician. Irrespective of the provider that you opt for, the benefit levels associated with in network services will be higher than out of network services. Choosing in network services will enable you to maximize the benefit coverage.

In the case of PPO plans, you might end up paying annual deductibles. In some instances, your provider will only pay for the medical bills after you have paid the deductibles. There are usually two different annual deductibles. One is applicable for providers that are in the network and the other for providers that are out of the network. And deductibles for the latter are higher.

Depending on your provider, you might end up paying $10 to $30 for some of the services as co-payment. In other cases, you must pay a certain percentage of the medical bills as co-payment.

PPO – Is it for You?

If you want to assess if a PPO plan is apt for you, here are some of the conditions where it works in the most efficient way.

  1. You need absolute freedom to choose a provider or medical facility for all your needs
  2. You are not keen on getting referrals for visiting a specialist for healthcare needs
  3. You wish out of network services to be covered as a part of your health plan

Being aware of some of the shortfalls of a PPO plan will help you better decide whether a PPO is for you or not. For starters, PPO plans tend to be a bit more expensive when you compare them with other managed-care plans. Typically, you will end up paying higher monthly premiums and deductibles should you opt for one.

And in most of the cases, you have copay and coinsurance, both. Also, it can be a bit tricky to keep a track of in-network deductibles and out of the network deductible.

However, PPO offers a lot of flexibility for its subscribers. They are known to offer better comprehensive coverage. PPOs also provide several services that other managed-care programs either simply do not offer or charge additional premiums for.

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