PPO

Freedom to choose

A PPO, short for preferred provider organization, gives you the most flexibility of the common plan types. You can see any doctor or specialist you want, without a referral. Providers in the plan's network cost less, and providers outside the network are usually still covered, just at a higher share.

That flexibility typically comes with a higher premium than an HMO with similar cost sharing.

How in-network and out-of-network costs differ

A PPO generally has two sets of numbers:

• In-network: a lower deductible, lower coinsurance and an out-of-pocket maximum that, on ACA-compliant plans, cannot exceed $12,000 self-only for 2027.
• Out-of-network: a separate, higher deductible, higher coinsurance and sometimes a higher cap or no cap.

Out-of-network providers can also bill you the difference between their charge and what the plan allows, known as balance billing.

Example

Ben runs a small landscaping company and travels between Tampa and a job site in Georgia. He has a PPO with a national network.

• In Tampa he sees his longtime doctor, who is in network. He pays a copay.
• On a job in Georgia, he sees an in-network urgent care clinic there. Same in-network rate.
• He wants a second opinion from a specialist who is not in his network. The PPO covers it at the out-of-network rate. He pays more, but he is not stuck with the whole bill.

With an HMO, the Georgia visit might only be covered if it were an emergency, and the second opinion would not be covered at all.

Who PPOs suit

• People who travel often or live in more than one state during the year.
• Families with children away at college.
• Anyone attached to specific doctors or hospital systems.
• Business owners who do not want referral steps slowing them down.

Marketplace vs private plans

PPOs are increasingly rare on the individual Marketplace in many states, including much of Florida, where HMO and EPO plans dominate. Private plans sold outside the Marketplace often use large national PPO networks. For people above the 2027 subsidy line, such as $63,840 for one or $132,000 for a family of four, a private PPO can be competitive with an unsubsidized Marketplace HMO. Private plans may use health questions and may handle pre-existing conditions differently, so it is important to understand what is covered before you switch.

Checklist before choosing a PPO

• Confirm your key doctors are in network, not just covered out of network.
• Look at the out-of-network deductible and whether there is a cap.
• Check how the plan handles prescriptions and specialty drugs.

Our guides on private vs Marketplace plans for the self-employed and health insurance without a subsidy cover when a PPO makes sense. To compare PPO options, get a quote.