What is a PPO?

What is a PPO?

A PPO is a type of health insurance plan. It stands for Preferred Provider Organization. With PPOs, you pay less when you see a provider who is in your insurance company’s network; that’s the favorite part. Your PPO has already negotiated a certain rate for health care services offered by these network providers.

You can also see many providers outside of the PPO network for medical care. However, you will generally pay more for out-of-network providers and medical services. That’s because there is no formal negotiated fee agreement between an out-of-network provider and your plan.

Why would a person choose a PPO over an HMO?

PPOs are one of the most popular types of health insurance plans due to their flexibility. With a PPO, you can visit any health care provider you want, including specialists, without first getting a referral from a primary care physician (PCP). This can be helpful if you’re not close to a doctor who’s in your provider network, like when you’re traveling, or if you already have a team of health care professionals you’re comfortable with, even if they’re out of network. 

The benefits of a PPO include the opportunity to choose the doctor and specialist you want without having to go to a primary care doctor initially, he explains. Yuna Rapoport, MD, MPH, an ophthalmologist at the Manhattan Eye in New York City. This places the patient in the driver’s seat.

PPO vs. HMO

PPOs aren’t your only option, of course. Another common type of health insurance plan is an HMO, or health maintenance organization. HMO plans have some key differences from PPOs that may affect your choice of the health insurance company.

With an HMO, you typically must see your PCP for a referral to see an in-network specialist. Your HMO also won’t cover visits to out-of-network providers unless it’s a genuine medical emergency, and even then, you may still pay part of the bill.

However, Dr. Rapoport says that HMO plans can be valuable to patients. The benefit of HMOs is from a systems-based perspective, she says. By maintaining a close relationship with a primary care physician, there are fewer unnecessary visits to specialists, less imaging, and fewer diagnostic tests. Results are comparable to or better than a PPO, and the system recommends patients to all of their doctors.

While getting a referral before seeing a specialist can be a hassle, it also means that your PCP is involved in your health in a way that doctors in a PPO sometimes aren’t, helping you coordinate care in consequence.

Cost Comparison

And, of course, you can’t talk about health insurance and not mention out-of-pocket costs. PPO networks typically have higher premiums, copays, and annual deductibles than HMOs in exchange for greater flexibility. If you see an out-of-network provider, you may have to pay the cost upfront and then file a claim for partial reimbursement. If you value flexibility and don’t mind paying more for it, a PPO might be the right health care option for you.

Health care costs with HMO networks are generally cheaper overall. You’ll have lower monthly premiums and copays in exchange for using a PCP to coordinate your care. However, you generally cannot see out-of-network providers with an HMO. If you do, you will be responsible for the full cost.

How do I know if I have a PPO?

Wondering what type of health insurance plan you have? It usually says so on the back of your insurance card. Your card may even list how much you’ll pay in copays for doctor visits. A quick call to your carrier or logging into your online account can also provide some clarity.

If you don’t already have a PPO and want to switch to one, you’ll need to do so during open enrollment —usually, but not always, in November or December—unless you’ve had a qualifying life event. Qualifying events include moving to a new zip code or county, getting married, or having a baby.

PPO plans may be available through your employer, your state marketplace (if there is one), or the federal marketplace. The best place to start with this option is healthcare.gov.

Medicare also offers a PPO Option (between HMO and other options) under Medicare Advantage (Part C) if you are 65 or older and eligible. Something to keep in mind when considering a PPO plan is that health savings accounts (HSAs) and flexible savings accounts (FSAs), along with things like your SingleCare card, can also help lower your health care costs and recipes.

Can I use SingleCare if I have Medicaid?

At SingleCare, we believe you should be able to get the best possible price for your prescription, regardless of your insurance status. That is, you can use the SingleCare Pharmacy Savings Card to lower your prescription prices, even if you are eligible for State Health Insurance or Medicaid benefits. That is not illegal, or against the rules.

How do you use SingleCare if you have Medicaid?

SingleCare can help you save up to 80% on prescription drugs, lowering drug costs so you have more money left over for your other essential expenses. All you have to do is visit our website. You can text the Rx card or print it right away. Whether it’s texted, printed, or emailed to you, you can use all three versions at the pharmacy.

It’s important to note: You cannot use SingleCare and Medicaid benefits at the same time. But you can use SingleCare if our prices are lower than Medicaid’s or if your benefits don’t cover a prescription. When you use your SingleCare card, the pharmacy processes it instead of your Medicaid card, not in conjunction with your Medicaid card. That is, you get savings on the cash price of that drug.

When can you use SingleCare instead of Medicaid?

Medicaid does not cover a prescription.

Prescription drug coverage is an optional Medicaid benefit. Currently, all states offer it and cover the cost of prescriptions. But they can decide which drugs they prefer and which ones are excluded. So all medications may not be included.

Let’s say you need a drug that costs $50 and Medicaid doesn’t cover it. SingleCare offers savings on many prescriptions. Depending on the drug and location, the price for SingleCare could be as low as $10. The pharmacist can use the SingleCare card or a SingleCare coupon to offer you the lowest price.

When SingleCare prices are lower than your copay.

States may impose copays for Medicaid services and prescriptions. What you’re responsible for Out of pocket is based on income. Depending on your or your family’s situation, your prescription copay could be $4, $8, or up to 20% of what the agency pays for non-preferred drugs. SingleCare’s price for a prescription may be lower than your Medicare copay. In that case, you can ask the pharmacist to use your SingleCare Rx card when you pay.

Compare the prices of your prescriptions.

You can use singlecare.com to compare which pharmacy has the lowest prices. Search for your location, then type in the name of your prescription. You will see several pharmacies and discount pricing options. You should compare our prices to the out-of-pocket (or cash) price of the drug. You can use SingleCare to lock in lower prices at major drug stores including CVS, Walmart, Walgreens, Albertsons, Kroger, Target, Longs Drugs, Duane Reade, and many more.

Wondering what the catch is? 

There isn’t one! SingleCare partners directly with pharmacies, which allows us to offer you lower prices. We receive a small fee from our partner pharmacies when you use your SingleCare card to save, which is how we can offer you the service for free. Pharmacies choose to do business with us because we keep our business practices transparent, our prices consistent, and we help drive customers to your pharmacy.

By Master James

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