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Who should consider PPO health insurance plans?

couple seeks information about PPO health insurancePPO health insurance plans are good for people who do not want to be restricted by an HMO but require an affordable plan. The policyholder must be okay with certain restrictions in the PPO plan.

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PPO health insurance plans are preferred provider organizations. These plans allow policyholders to visit whichever providers they choose. However, the benefits of the policy will be higher for providers that are in-network than providers that are out of network.

What do PPO health insurance plans cover?

PPO health insurance plans are usually comprehensive medical plans. PPO health insurance plans cover:

  • Prescription medications
  • Physician visits
  • Emergency care
  • Hospitalization
  • Surgery
  • Laboratory tests

Do PPO health insurance plans have large networks of providers?

PPO health insurance plans have larger networks of providers than HMOs due to the insurance company’s contractual agreements with the providers.

PPO health insurance plans usually pay more to the provider, because the PPO plan policyholder has a larger co-payment than the policyholder does of an HMO plan. Since the policyholder pays more to the provider, it allows the insurance company to pay more to the provider, which of course is beneficial to the provider.

Are there premiums with a PPO?

There are premiums with a PPO. Premiums may be paid on a weekly, monthly, or quarterly basis depending on the plan and insurance company. The premium amount will also vary depending on the plan and insurance company.

Are there co-payments with a PPO?

There are co-payments in a PPO, so individuals that consider a PPO must be willing to make co-payments. The co-payment amounts are pre-established between the insurance company and providers.

Co-payments are often a set amount or a percentage of the office visit or procedure. On average, co-payments can range from $10-$50 or be as high as $200.

Co-payments on a PPO plan are often higher than that of an HMO plan. PPO plans often have the option of having an HSA account to help defer the expenses of PPO co-payments. Policyholders can deposit pre-tax money into an HSA account to be used for medical expenses.

Are there deductibles with a PPO?

There are usually deductibles with a PPO, so individuals that consider a PPO must be willing to meet the deductible. The deductible will vary depending on the insurance company and plan.

Policyholders must meet the established deductible before the plan switches to an 80-20 split between policyholder and insurance company. Depending on the plan, some insurance companies will begin to pay 100% of medical expenses once the deductible is met.

Deductibles can range from $1000 and up, so this is something to consider before purchasing a PPO plan.

What are the restrictions on a PPO plan?

The restrictions on a PPO plan are not as strict as an HMO plan in that you do not have to see a primary care physician to obtain a referral to a specialist. PPO plans allow you to see specialists, but in-network specialists will cover more of the out-of-pocket expenses than out of network specialists.

When you see an out of network provider, you will have to pay a co-insurance amount. This can be anywhere from 20-40% of the cost of the visit or procedure depending on the insurance company and provider. The co-insurance is usually the amount between what the provider charges and what the insurance company is willing to cover.

What about out of pocket expenses in a PPO plan?

PPO plans establish a set amount of out of pocket expenses. Once the policyholder has reached the cap of out of pocket expenses, they are no longer required to pay them. The insurance plan will pay anything over that amount.

What about caps on a PPO plan?

Many PPO plans have caps on how much they will cover per policyholder. If you meet this cap, you may be responsible for any medical expenses over that amount. However, the Health Care Reform Act is doing away with lifetime caps. It will occur as a progression until the caps are completely gone according to the Health Reform Report.

What is the percentage of people enrolled in a PPO plan?

The percentage of people enrolled in a PPO plan according to Consumer Reportsis 34% of Americans. This percentage will most likely increase as many HMO plans are going away.

What about insurance claims?

Depending on your plan, either the provider will file the claim for you or you may have to file the claim yourself. This is something to consider if you are not good with paperwork.

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