FAQs About Group Health Insurance PPO Plans

If you are a business owner, or an employee who qualifies to receive health insurance from your employer, then you will naturally want to learn more about the benefits provided within the available plan(s). After all, employer-sponsored insurance is often one of the most budget-friendly insurance solutions for most Americans. Therefore, you might feel tempted to enroll without a second fault. Still, the choice to enroll in coverage is not to be taken lightly.

One group health insurance option available from major insurers is a PPO (Preferred Provider Organization) plan. PPOs are expansive health insurance options that can help you get the care you need affordably. However, they have their limits and terms attached, too.

Therefore, let’s take a look at group health PPOs a little more closely, and consider some of the frequently asked questions about these options in particular.
couple getting insurance

What is Group Health Insurance Plan?

Employers frequently offer group health insurance options for their employees, simply because these plans are structured to cover a large number of people under similar terms. The business is the primary policyholder. However, employees can enroll themselves (and often their family members) as participants in the plan. The employee retains the right to keep their medical care choices private.

Under the terms of the plan, the employer and the employees share in the policy’s premium costs. For example, though you might pay $400 for a plan if you bought it by yourself, by enrolling in your employer’s group option, your employer might agree to pay $300 of that cost while you only pay the remaining $100.

You will also be able to have this portion of your premium deducted from your paycheck in most cases. Therefore, you won’t have to worry about making a separate individual premium for your policy after you receive your net pay for the month.

What is a PPO?

A preferred provider organization (PPO) is a fancy name for a health insurance plan that usually gives you a high degree of choice when picking the medical care that is right for you. All in all, it allows you flexibility to see the providers that are most convenient for you.

Your plan will include a physician, pharmacy or provider network. By seeing a provider within your network, you will receive optimized pricing. However, you can see providers that are outside your network, though your coverage will be lower as a result.
Most PPO plans do not require you to name a primary care provider (PCP) within their network. You will not have to receive a referral in order to receive specialist care, either.

What is a PPO Provider Network?

The provider network on your PPO is a list of doctors, facilities and other care providers who accept your plan as a form of payment. The providers within your network are those who offer the most premium level of pricing for all plan options. Therefore, by seeing these providers, you will pay the lowest out-of-pocket cost for your care.

However, if you need to receive care outside of your provider network—such as in an emergency—then you will often find that you still have covered care available. However, this coverage is not universal, and even if your plan covers an out-of-network provider, you will have to pay a proportionally higher cost.

How Much Will I Pay for Care Under a PPO?

Though you can receive optimized health care coverage by seeing a provider in your PPO network, you will often still be responsible for certain out-of-pocket expenses.

Depending on the care you receive, a combination of the following requirements might apply:

Coinsurance: Under a coinsurance agreement, your plan agrees to pay for a percentage of your care cost, while you pay the rest. For example, if you have a 70/30 coinsurance agreement on your plan, then your plan pays for 70% of your care costs, while you pay the remaining bill. In other words, if you have a $500 medical procedure, then your plan will pay for $350 worth of your care, and you will pay the remaining $150.
Co-payments: A copayment is a nominal fee that you are required to pay at the time you receive certain services. You will often pay copayments for check-ups, lab services and similar services. For example, if you see your regular physician, your copay might be $30, while a specialist copay would be $40.

Deductibles: Certain medical services will not be covered until you meet the deductible on your plan. Until you have met the deductible, you will be required to pay for 100% of your care costs. A $2,000 deductible will mean paying $2,000 out of pocket for care before your plan begins to cover you.

However, it’s important to remember that different services will be subject to different cost requirements. For example, you might only be required to pay a copayment for a physician’s office visit, and your deductible will not apply. However, if you have to have an MRI, then you might find that the cost of this procedure won’t be covered until you have met your deductible.

If you’re curious about the terms included in your employer’s group health PPO, then don’t hesitate to contact your benefits manager and your insurer directly. They will help you determine exactly what you can expect to pay for coverage.

FAQs About Group Health Insurance PPO Plans

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