What is a PPO?
Preferred Provider Organization (PPO)
A PPO is a type of health plan that offers members the most freedom to see providers in and out of the plan’s network without referrals. While members can use providers outside the network, they will have higher out-of-pocket costs, and some services may not be covered.
What are the characteristics of a PPO?
Flexibility afforded by a PPO
PPO plans offer some of the greatest flexibility of all the plan types. PPO members manage their own care. This means PPO members:
- Are not required to choose a primary care physician (PCP)
- Can see a specialist without a referral
- Are free to use providers both in and out of the network
How networks work with a PPO
All health insurance plans have contracted with doctors and hospitals to provide care to the plan’s members. These providers are called network providers or in-network providers, and they include PCPs, specialists, and even facilities, like labs, hospitals, and urgent care centers. A provider that isn’t contracted with the plan is called an out-of-network provider.
PPO members are covered for care from both in-network and out-of-network providers — but they’ll pay less when they choose doctors and hospitals in the network and more for out-of-network providers.
PPO and PCPs
A primary care physician (PCP) is the doctor you visit for most of your health care needs. PPO plans do not require you to choose a PCP, and if you need to see a specialist, simply make an appointment. You don’t need to get a referral.
Deductibles and copays with a PPO
In addition to a monthly premium, PPO members will also have out-of-pocket costs — copays and deductibles — when they receive care.
- Copay: The set amount members pay for a covered health care service. For example, the copay to see a doctor could be $20, while the copay for an emergency room visit could be $100.
- Deductible: The amount a member pays each year before the health plan starts to share the costs. For example, if the plan has a $1,000 deductible, the member pays the first $1,000 of the costs for the services received. Once the deductible has been met, the insurance will pay for some or all health care services, depending on the health plan.
What are the pros and cons of a PPO?
Understanding the pros and cons of a PPO health plan is helpful when comparing your options.
Advantages of a PPO
- You don’t have to choose a PCP.
- You can go to doctors in or out of the plan’s network.
- You can see doctors, hospitals, and other health care providers of your choice, without a referral.
Disadvantages of a PPO
- PPO plans tend to have higher monthly premiums than other types of plans.
- You will pay more if you use an out-of-network doctor or provider.
PPO compared to HMO (Health Maintenance Organization)
Here’s a short list of the most notable differences between HMO and PPO health plans.
The main differences between an HMO and PPO are:
- HMO plans require you to choose a PCP.
- HMO plans require you to get referrals to see most specialists.
- PPO plans cover services from out-of-network providers. HMO plans only cover out-of-network care in the case of an emergency.
- HMO plans generally cost less than PPO plans.
Want to learn more about HMOs? Take an in-depth look: What is an HMO?
PPO compared to an EPO (Exclusive Provider Organization)
Like a PPO, an EPO does not require members to select a primary care physician (PCP) or get referrals to see specialists. Unlike a PPO, EPO members are required to use in-network providers (except for urgent and emergency care). Want to learn more? Check out What is an EPO?
Who would a PPO plan be a good fit for?
If you need the flexibility to see both in- and out-of-network providers, then a PPO may be a good fit for you. With a PPO, you’ll have access to an extensive network of doctors and hospitals and the freedom to see any doctor or specialist without a referral. But you’ll pay lower costs when you use in-network providers and higher costs for out-of-network providers.
What PPO plans are available from AmeriHealth?
Currently, AmeriHealth does not offer PPO plans to individuals and families. They are only available through our employer groups. If your employer offers AmeriHealth coverage, talk to your benefits administrator to learn more about your plan options.
Know your options and find your plan
- Compare all our plans and apply for coverage. Get started.
- Depending on your income, age, and the number of people in your household, you may be eligible for financial assistance. Find out if you qualify.
If you have questions, please call one of our AmeriHealth representatives or refer to our Frequently Asked Questions (FAQ).