Who Benefits Most from a PPO?


PPO health insurance is one of the most common types of managed care plans available for Americans, but if you don’t know the difference between the various options, you could be missing out on some benefits–or worse yet, putting yourself in at a disadvantage.

PPO medical insurance works by providing members with a network of preferred provider organizations to go to for their medical needs. Doctors, hospitals and other medical providers in this network will usually charge at a discount because they are in the network.

Unlike HMOs, this type of health insurance is not limited to just in-network providers. You have the option to go out of network, but will most likely have to pay more. Some other PPO advantages include not needing a referral to see a specialist and speedier processes for seeing multiple medical service providers.

However, PPO insurance generally is more expensive and requires members to meet annual deductibles before they qualify for coverage.

PPO Advantages

Since everyone’s medical conditions and needs are unique, there are definitely some factors to consider when deciding whether PPO benefits are the right fit for you. Here are some of the advantages that having PPO insurance provides:

  • Wider range of coverage for available health care providers
  • Less restrictions and more flexibility to handle your medical needs
  • Primary care physician not required
  • In-network providers charge a reduced rate for services

PPOs are preferable for people have more complicated medical needs and want the freedom to see multiple health professionals without having to go through their primary care physician first for a referral. In addition, if you have a specific doctor or surgeon who isn’t covered by an HMO plan, getting a PPO helps to resolve that issue.

PPO Disadvantages

While these types of medical plans offer greater flexibility, they do come with higher costs. While the in-network providers provide discounted pricing, the main beneficiary is the insurance company, not the policyholder. Here are some other factors to consider:

  • More expensive premiums than HMOs and some other plans
  • Co-payments are also usually higher
  • Some PPOs require an annual deductible to be met before coverage begins
  • Out of network coverage is significantly less than in-network coverage

Again, depending on your medical needs, a PPO may or may not make financial sense to you since there are higher costs in just about every aspect of a PPO as compared to an HMO. If you rarely need to go to the doctor and don’t accrue too many medical expenses, a PPO isn’t right for you. If you don’t have enough medical expenses to meet the deductible, it defeats the purpose of having the plan in the first place.

Should You Choose a PPO?

If you are healthy and don’t foresee any significant need for medical treatment or attention any time in the near future, having a PPO would not be smart. You’d be paying extra for network flexibility you don’t necessarily need.

However, if you have many types of ailments or are in need of more complicated treatments and medical opinions, it may make sense for you to get a PPO plan. It resolves a lot of the headaches that HMO restrictions may produce.

Obviously, your health comes first. Decide what you actually need to keep you medically sound and then proceed from there. Sometimes paying for more can actually save you in the long run.