Is PPO Insurance Worth the Cost?

PPO plans give you more choices when picking health care providers than other types of insurance. In a PPO plan, you have a network of “preferred” providers. These include doctors and specialists who can offer care at the lowest out-of-pocket cost, compared to out-of-network providers.

With PPO insurance, you can also choose to see a doctor who is not in the preferred network. While you typically pay less to see in-network providers, the plan will pay part of the cost even if you go outside the network. This can be especially important if you prefer specific doctors or hospitals. It is also useful if you travel frequently and need care away from home.

HMO plans often have lower premiums. However, they have stricter rules about which doctors you can see. HMO plans limit your coverage to providers in their network. If you go to a provider outside the network, you will likely have to pay the full cost of your visit.

With a PPO plan, you are not required to select a primary care doctor. One particular feature of a PPO plan that people like is that you do not need a referral to see a specialist.

“PPO plans allow more choice. It gives patients the power to either change doctors or seek second opinions anytime without approval, which allows you more flexibility,” says Anil N. Keswani, MD, Scripps Health Chief Medical and Operations Officer, Ambulatory Care.

HMO plans require you to choose a primary care physician (PCP) from their network. This doctor is often the first person you will see any time you need care. If you need to see a specialist like a cardiologist or orthopedic surgeon, you must request a referral from your primary care physician.

The HMO usually needs to approve your referral before your visit to the specialist is covered. If the referral is denied, you’ll have to pay out of-pocket for the visit and any follow-up care.

With an HMO plan, women usually can choose their gynecologist as their primary care physician and see them without a referral.

Many PPO plans offer coverage nationwide. This gives you more flexibility if you travel frequently or live in different places during the year. You do not have to find an in-network provider.

Be aware that neither a PPO nor an HMO health plan covers you outside the U.S.

HMO plans restrict coverage to your local region. You won’t be covered if you seek care outside that region. However, emergency and urgent care are usually covered.

It’s important to weigh the value of the flexibility PPOs offer against the higher cost when deciding if a PPO plan or an HMO plan is right for you.

If you choose a PPO plan, here are a few things to consider:

PPOs offer flexibility, but it comes at a cost. PPO plans usually have higher monthly premiums than other health insurance plans. When looking at a PPO plan, consider both the flexibility it offers and the higher costs to see if it suits your needs.

If you rarely seek medical care beyond your annual checkup and you have a strong relationship with your primary care doctor in the network, an HMO may save you money. Just remember, you have more limited options of which providers you can see.

Out-of-pocket costs are expenses you pay in addition to premiums, such as copayments and deductibles. PPO plans typically have higher out-of-pocket costs and may have higher deductibles.

Scripps doctors and hospitals accept many health insurance plans, including PPO and HMO plans.

“Scripps and many other health care systems have providers who accept both HMO and PPO plans, so whether or not a PPO health plan is worth the extra cost ultimately depends on your preferences, your health care needs and your budget,” says Dr. Keswani. 

Call 858-879-3120 with questions about San Diego health insurance plans accepted at Scripps.