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PPO Costs

PPOs are more costly and more complex than HMOs, and you have more paperwork. In a PPO, you can see providers inside or outside the network. The PPO pays part of the cost either way, but it pays less if you go out of the network.

Ask your employer or plan for a summary of your costs. Use this worksheet to list them.

Costs: What's What
In-network costs

premium

The fee the PPO charges each month to maintain your coverage.

  • The total premium is what you pay PLUS what your employer pays.

co-pay

The flat fee that you pay each time you see a doctor or get services.

  • Doctor visits, prescription drugs, emergency room visits, and hospital stays have different co-pays.

co-insurance

Some PPOs charge you a co-insurance instead of a co-pay. The co-insurance is a percent of the cost of a service.

yearly deductible

Some PPOs have a yearly deductible. This is the amount you must pay each year to providers before your PPO pays anything.

  • In some plans, the yearly deductible does not apply to preventive services.
  • You may pay a separate yearly deductible for prescription drugs.
  • Plans with high deductibles (over $1,200/year) have special rules.

out-of-pocket maximum

This is the total you have to pay each year for most of your services.

  • However, you still pay co-pays for some services, including prescription drugs and most medical equipment, even after you meet your yearly maximum.

hospital costs

If you have a co-pay for a hospital stay, it can be several hundred dollars.

  • If you pay a co-insurance, you pay a percent of the hospital costs. This can be very expensive.
  • Learn more about hospital costs.
Out-of-network costs

If you see a provider outside the network, your cost will depend on the PPO’s usual rate for the service. This amount may be less than the doctor or other provider actually charges for the service, but it is the most your PPO will pay. You usually have to pay the rest.

Before you see an out-of-network doctor, ask your PPO how much it will pay. And ask the doctor’s billing staff what the charge will be.

Learn more about out-of-network costs  .

 

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