Pros and cons of PPO health insurance plans

46515613 - group of medical doctors over hospital background. health care.Whether this is your first time shopping for your own health insurance or you’ve been with an HMO company for most of your life and you’re considering a switch, don’t jump into a PPO insurance plan before evaluating these pros and cons to see if it’s right for you and your health care needs:

Pro: Flexible Network of Providers

One of the biggest advantages of a PPO plan is that you have access to substantially more medical providers than you would with an HMO plan. You can switch doctors and facilities if you’re unhappy with your current ones, and you can easily find out who accepts your insurance by searching different services and doctors in your area through a PPO’s online search portal.

Con: Cost Confusion

HMO plans are relatively streamlined, while PPO plans aren’t as simple. First, you have to figure out the difference between in-network and out-of-network providers (and these providers may eventually change their status with your PPO insurance company). There are typically low co-pays charged for services rendered by in-network providers, while out-of-network providers may require co-insurance payments (percentage of the cost of services received).

There are also deductibles to think about with a PPO insurance plan (while many HMO plans have no annual deductible). HMO plans are generally cheaper in terms of monthly premiums, but you’re 100% responsible for costs incurred at out-of-network provider facilities, so the higher monthly cost for a PPO plan might be worth it just for the flexibility.

Pro: More Service Availability

A PPO insurance plan allows you to access a vast range of services, including preventative care, mental health services, prescriptions, specialist treatments, surgeries, fertility treatments and maternal care, physical check-ups, and much more. Depending on the available HMO plans in your area, a PPO may offer significantly more services than your typical HMO (especially since you’re not limited to one medical provider and get access to a fuller network of providers in your area).

Con: Unclear Rules and Restrictions

When you have a PPO insurance plan, there’s a small chance you might run into some issues with finding an in-network provider and figuring out claims and billing procedures for out-of-network doctor care or hospitalizations. For instance, some medical facilities’ websites say they accept a wide variety of insurance plans, but that doesn’t always mean they accept your specific plan or one of the doctors at the facility is a participating provider in your PPO network.

This can lead to some costly mistakes if you don’t directly ask them about their partnership with your PPO company before seeking treatment there. Furthermore, there may be a different company responsible for different services (for instance, some PPO companies have separate administrators for mental/behavioral health services), so as with any type of plan, it’s always a good idea to check with your insurance company well in advance of your appointment or procedure.