PPO health insurance plans are a popular choice for individuals and small businesses because they offer comprehensive coverage with a lot of flexibility when it comes to the healthcare providers, hospitals, and services you can use.
But what is PPO insurance, exactly? We’ll break that down here, including how this type of plan works, its pros and cons, how it compares to other health insurance plans, and how to choose the best plan for your needs.
What Is a PPO Plan?
A PPO is a type of private medical insurance plan that gives members access to a network of healthcare providers and facilities. Policyholders pay less for care within this network. They can also seek care outside the network at a higher cost.
PPO insurance plans are the most common type of health plan among U.S. workers: Nearly half of all covered employees were enrolled in this type of plan in 2023, according to a health benefits survey by KFF, a health policy organization that conducts research and polling.
PPO plans are also available to self-employed folks and business owners. Here at OneHealth, we connect successful individuals and small businesses of up to 50 people with nationwide PPO health insurance plans that are typically more affordable (20 to 40 percent less expensive) than comparable plans offered through the federal Health Insurance Marketplace. Learn more about our plans and get a quote.
What Does PPO Stand For?
To understand PPO’s meaning, let’s break down the acronym: It stands for Preferred Provider Organization.
So, what is a preferred provider? A Preferred Provider Organization or network is basically a group of doctors, healthcare facilities, and other healthcare providers (think: physical therapists, psychologists) that an insurance plan partners with to provide medical care to its members. The providers in the group are known as in-network providers, and they offer care at a lower price to policyholders. A provider that isn’t on the list is considered an out-of-network provider.
How Does PPO Insurance Work?
These plans are born from a negotiation between the PPO insurance provider and a large group of healthcare providers: The healthcare providers agree to accept lower fees for their services in return for being listed among the insurance plan’s preferred providers, making them more appealing to policyholders looking for in-network care.
When you go to an in-network provider for care, the provider is paid by the insurance company on a fee-for-service basis, meaning they’re paid a certain, agreed-upon amount based on the service they provided.
PPO plan members are typically responsible for paying a monthly premium as well as copays or coinsurance and sometimes a deductible amount. These are considered out-of-pocket expenses, which we’ll break down below.
Premiums
PPO plan members pay a monthly premium for their coverage, whether they use it or not. According to KFF’s 2023 report, the average monthly premium for employer-sponsored PPO health insurance is about $742 for an individual ($8,906 per year) and about $2,100 for family coverage ($25,228 per year), which is higher than the overall average of $700 and $2,000, respectively.
The cost of a PPO plan through the federal Health Insurance Marketplace varies greatly depending on where you live and factors like your age, health status, and the exact plan you choose. For example, the cost of an individual PPO plan for a 30-year-old non-smoker in Miami might be about $1,400 per month, while the same plan might cost about $1,100 per month in Palm Beach, Florida. The Marketplace doesn’t offer PPO plans in every state, though.
Individual plans through OneHealth also vary in cost based on factors like age and health status, but unlike the Marketplace, our rates don’t change based on where you live. Individual PPO plans through OneHealth start at $500 per month, and the average monthly premium is $650.
Copays and coinsurance
Copays and coinsurance are the portion you pay for the care you receive. A copay is typically a set amount, like $20 for a visit with your primary care provider or $50 when you see a specialist. Coinsurance is usually a percentage of the total cost of a service, like 20 percent of the cost of an MRI (your plan pays for the rest).
Copay and coinsurance amounts vary plan to plan, but plan members typically receive a breakdown of this information when they enroll. A 2020 study of health benefits found the average coinsurance rates for people with an employer-based insurance plan were 18 percent for primary care services, 19 percent for specialty care, and 20 percent for hospital stays.
Deductibles
A deductible is the amount you must pay out-of-pocket for covered medical care before your insurance plan starts to help cover costs. If you have a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. This amount resets at the beginning of every new plan year.
Your deductible, along with copays and coinsurance, counts toward your plan’s out-of-pocket maximum, which is the highest total amount you’ll pay for covered services in a year. After you hit that dollar amount, your plan pays 100 percent of your covered medical costs.
In 2025, the max out-of-pocket cost for a federal Health Insurance Marketplace plan (and other plans, like those offered through OneHealth, that are ACA-compliant) can’t be more than $9,200 for an individual or $18,400 for a family.
Benefits of PPO Insurance
PPO insurance plans are popular because they come with quite a few perks. The core benefits of PPO insurance include:
- Large provider network: PPO policies offer access to a large group of providers and hospitals that participate with the plan, giving you the freedom to choose where and from whom you get care. Unlike some other plans that have smaller provider networks, PPO networks typically include providers in all 50 states. The PPO plans offered through OneHealth, for example, include more than 1.3 million in-network providers. For this reason, PPO plans are a good choice for people who travel often, live in more than one place, or have dependents who live or work in different states (like kids in college, for example).
- Flexibility: PPO plans also allow you to see out-of-network providers. The cost for these visits is higher than what you’d pay to see an in-network provider, but you won’t have to pay the entire amount out-of-pocket like you would with some other plans.
- No referrals needed: Plan members can see a specialist without a referral from their primary care provider, saving you the time and cost associated with an extra appointment and giving you more freedom to choose which specialists you see.
- No need to select a primary care provider: Unlike some other plans, PPOs don’t require you to have a single primary care provider on file. This may be more convenient for people who travel often or are otherwise unable to see the same doctor consistently.
Like many other types of insurance plans, PPOs cover all or some of the cost of many drug prescriptions, and most fully cover the cost of preventive care visits like annual well visits, cancer screenings, and prenatal care.
Disadvantages of PPO Insurance
A PPO plan isn’t the right fit for everyone. Although there are a lot of pros to these policies, they also have some disadvantages, including:
- Higher premiums: PPO plans are generally more expensive than other types of insurance plans when it comes to monthly premiums.
- Out-of-pocket expenses: Most PPO plans come with an annual deductible, which is the amount you must pay yourself for medical expenses before your insurance plan starts to help cover those costs. The average deductible amount in 2023 among workers with single coverage, according to KFF, was $1,735. If that’s your deductible, that means you pay the first $1,735 of your medical expenses for the year out of your own pocket, and then your plan’s cost-sharing benefit kicks in. PPO plans aren’t the only type of insurance plans that come with deductibles, though, and some are set up as high-deductible healthcare plans (HDHPs) with a health savings account (HSA) that allows you to use pre-tax dollars to pay for these kinds of out-of-pocket medical expenses.
- Paperwork: You typically won’t need to file claims or paperwork if you see an in-network provider, but you may need to do so if you see an out-of-network provider.
- Networks are stronger in some areas than others: Although PPO networks stretch across the country, some areas have fewer providers than others. Before you enroll, it’s a good idea to search your area for doctors and hospitals that participate in the plan you’re considering.
PPO vs. Other Insurance Plans
PPOs may be the most popular type of insurance plans, but there are other options, including HMO (Health Maintenance Organization), EPO (Exclusive Provider Organization), and POS (Point of Service) plans. Here’s how they compare.
PPO vs. HMO
There are many differences between HMO and PPO plans. PPO plans are typically more expensive than HMO plans, but they offer a larger network of providers and more flexibility in where and how you receive care.
| PPO | HMO | |
| Cost | Higher premiums | Lower premiums |
| Provider network size | Large network, usually nationwide | Smaller regional network |
| Out-of-network care | Covered at a higher rate | Only covered for medical emergencies |
| Specialist referrals | Not required | Required |
| Primary care provider | Not required | Required |
PPO vs. EPO
PPO plans offer more comprehensive coverage than EPO plans, but they’re typically more expensive.
| PPO | EPO | |
| Cost | Higher premiums | Lower premiums |
| Provider network size | Large network, usually nationwide | Depends on the plan |
| Out-of-network care | Covered at a higher rate | Usually only covered for medical emergencies |
| Specialist referrals | Not required | Usually not required |
| Primary care provider | Not required | Depends on the plan |
PPO vs. POS
POS plans usually cost less than PPO plans but offer less flexibility because they require you to choose a single primary care provider and get referrals for specialist care.
| PPO | POS | |
| Cost | Higher premiums | Lower premiums |
| Provider network size | Larger network | Smaller network |
| Out-of-network care | Covered at a higher rate | Covered at a higher rate |
| Specialist referrals | Not required | Required |
| Primary care provider | Not required | Required |
What’s PPO Dental Insurance?
PPO dental insurance is similar to PPO medical insurance. With a PPO dental plan, you get access to a large network of dental providers, and out-of-network care is covered as well, albeit at a higher cost.
Dental PPO plans are typically more expensive than other types of dental insurance, but that buys you more flexibility in your dental care, including the freedom to see a specialist without a referral. You also don’t need to choose a primary care dentist with this type of plan.
PPO dental insurance plans are available through OneHealth for individuals and small businesses.
How to Choose the Best PPO Plan for You
Picking the right health insurance plan (for yourself or your business) can feel overwhelming, but here are a few things to consider before you make your decision:
- Ask yourself what level of coverage you need: The most expensive plan isn’t necessarily the best plan if you and anyone else you’re covering have relatively few medical needs. If you anticipate using your coverage mostly for preventive care and the occasional sick visit, you may want to choose a plan with a lower monthly premium and higher out-of-pocket expenses such as deductibles and coinsurance.
- Do the math: Add up the total premium amount plus the total out-of-pocket maximum amount and compare that across all available plan options. Then work backward, asking yourself how often you’re likely to use a certain service in a given year. This will help you shape your anticipated costs for the entire year and determine which plan makes the most sense financially.
- Look into HSA options: Some PPO plans come with an HSA that allows you to set money aside pre-tax in order to pay for eligible medical expenses. If you choose a plan with a higher deductible, an HSA could help you save money on those out-of-pocket expenses as well as costs like copays and coinsurance.
If you’re self-employed or a small business owner and looking for a PPO plan to cover yourself and/or your employees, give us a call. Our Benefits Concierge Team is available to walk you through your plan options with OneHealth and help you decide which level of coverage is best for you.
OneHealth’s PPO Insurance Options
OneHealth helps successful individuals and small business owners with up to 50 employees access high-quality PPO plans tailored to their needs. Here’s what sets us apart from other companies that offer PPO insurance:
- Affordability: Because of our unique position in the market, OneHealth is able to offer individual plans at group rates. That makes our coverage up to 40 percent more affordable than comparable plans through the federal Health Insurance Marketplace for people who don’t qualify for subsidies.
- Flexibility: OneHealth offers access to Cigna’s nationwide PPO network, giving you the freedom to choose from more than 1.3 million in-network providers.
- Service: OneHealth’s Benefits Concierge Team is available to help walk you through everything from enrollment to filing claims.
- Security: No spam here. OneHealth never sells information to third parties. Your information is safe with us.
- Ease of use: Members can keep track of all their benefits through OneHealth via one convenient, state-of-the-art platform.
- Extras: OneHealth is a one-stop shop for all your health coverage needs. In addition to PPO insurance plans, members can access a full suite of ancillary benefits, including dental, vision, pet, and life insurance as well as accident, hospital, and critical illness plans.
“A PPO plan is a great option for people who want more flexibility and accessibility to care and have the means to spend a little more on their health insurance premiums,” says Brian Miller, COO and co-founder of OneHealth. “The PPO plans through OneHealth are more affordable than comparable plans, making them unique among health insurance options for self-employed people and small businesses.”
Explore our plans and contact us to get a quote today — it takes just five minutes to apply.
Key Takeaways:
- PPO health insurance plans give policyholders access to a large network of providers along with other perks, like the ability to see specialists without a referral, but they’re typically more expensive than other types of health insurance plans.
- PPO plans aren’t right for everyone, but they may be a good choice if you travel often, live in more than one place, have dependents who live in other states, or generally want more flexibility when it comes to your medical care.
- OneHeath offers self-employed folks and small businesses access to reputable PPO plans along with the service, technology, and additional benefits you won’t find anywhere else.
Ready to upgrade your health insurance plan?
