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Home > Health Insurance Basics > Health Care Costs > PPO Costs

PPO Costs

PPOs are usually 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.

 

In-network costs

Costs: What's What

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

Many 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 most 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 may still pay co-pays or co-insurance for some services, such as prescription drugs or medical equipment, even after you meet your yearly maximum.
Hospital costs

The co-insurance or co-pay for a hospital stay can cost a lot.

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

Out-of-network costs

If you see a provider outside the PPO network, your cost will depend on the PPO's allowed amount or usual rate for the service. If the provider charges more than the allowed amount, you have to pay the extra. You also have to pay part of the allowed amount.

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.                

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