PPO High vs PPO Standard: Key Differences Explained

Choosing between a PPO high and PPO standard health insurance plan can be confusing. While both are preferred provider organization plans that offer access to care within a network of healthcare providers, there are some key differences.

This article will explain what PPO high and PPO standard mean, compare the two plans, and provide tips on choosing the right option for your needs.

What is a PPO High Plan?

A PPO high plan is a type of preferred provider organization (PPO) health insurance plan with a higher monthly premium and lower deductible compared to a PPO standard plan.

Some key features of PPO high plans:

• Higher monthly premiums – You pay a higher upfront cost each month for the insurance coverage. Premiums are usually deducted from your paycheck.

• Lower deductible – The deductible is the amount you pay out-of-pocket before your insurance starts covering medical costs. PPO high plans have a lower deductible, often around $500 – $1000 for an individual.

• Lower coinsurance – After meeting your deductible, you typically pay a percentage of costs called coinsurance. PPO high plans have lower coinsurance rates, like 10-20%.

• Lower out-of-pocket maximum – This is the limit on your total costs each year. PPO high plans have lower out-of-pocket maximums, around $2000 – $4000.

• Smaller provider network – PPO high plans offer access to a network of preferred providers. However, the network may be smaller than a PPO standard plan.

• No HSA eligibility – You cannot pair a PPO high plan with a Health Savings Account (HSA).

What is a PPO Standard Plan?

A PPO standard plan also provides access to a network of preferred providers with negotiated rates. However, compared to a PPO high plan, you’ll pay lower monthly premiums but have a higher deductible and out-of-pocket costs.

Here are some key details on PPO standard plans:

• Lower monthly premiums – You’ll pay a more affordable upfront monthly cost for coverage. Premiums are usually deducted from paychecks.

• Higher deductible – PPO standard plans have a deductible of at least $1500 for an individual, often ranging from $1500 – $5000. You pay this amount out-of-pocket before coverage kicks in.

• Higher coinsurance – Your share of costs, like 20-40% of covered expenses, will be greater after meeting the deductible.

• Higher out-of-pocket maximum – This cap on your total costs for the year will be higher, often $5000 – $8000.

• Larger provider network – The network of healthcare providers you can visit will typically be larger with a PPO standard plan.

• HSA eligibility – You can pair a PPO standard plan with a tax-advantaged Health Savings Account to save for medical expenses.

PPO High vs PPO Standard: Key Differences

How exactly do PPO high and PPO standard plans compare? Here is an at-a-glance look at some of the key differences:

As you can see, with a PPO high plan you’ll pay more each month but have lower out-of-pocket costs when you need care. The PPO standard costs less monthly but you’ll pay more at the point of care until you hit your deductible and out-of-pocket maximum.

Which Plan is Better – PPO High or PPO Standard?

When choosing between PPO high and PPO standard, there are several factors to consider:

1. Your budget

Look at the monthly premiums and see what fits your budget. PPO high plans have premiums $100 or more higher per month than PPO standard. Make sure you can afford the monthly costs.

2. Your health

If you rarely visit the doctor or take prescription medications, a PPO standard plan may suit you well. But if you have chronic conditions or expect significant medical expenses, a PPO high option could save you money in the long run.

3. Your financial situation

Someone with an emergency fund to cover medical costs may do fine with a PPO standard plan’s higher deductible and coinsurance. Those without savings may prefer a PPO high option to limit out-of-pocket costs.

4. Plan details

Look beyond just premiums, deductibles, and coinsurance rates. Check that your medications, doctors, and hospitals are in-network. Also understand how referrals to specialists work.

5. HSA eligibility

If you want to open a Health Savings Account (HSA) to save and invest for healthcare expenses, choose a PPO standard plan since PPO high options don’t allow HSAs.

Tips for Choosing Between PPO High and PPO Standard

Follow these tips when deciding between PPO high vs PPO standard:

• Use your insurance company’s online tool or speak to a representative to compare detailed plan benefits and costs. Don’t just look at the premium.

• Calculate your total estimated costs for the year under each plan based on your expected medical usage. This can give you an idea of potential out-of-pocket costs.

• Make sure your preferred healthcare providers and facilities are in-network for the plan you choose.

• Ask about referral procedures to see specialists for each plan.

• Look closely at prescription medication coverage. Check if your drugs are covered and at what cost tier.

• Consider pairing a PPO standard plan with a Health Savings Account to save and invest pre-tax dollars for medical expenses.

• Choose a lower deductible if you don’t have emergency savings to cover out-of-pocket medical costs.

• Pick a higher deductible plan if you rarely visit the doctor and want to pay lower premiums.

When are PPO Plans a Good Choice?

PPO high and PPO standard plans can both be great options if:

• You want access to healthcare within an established network of providers.

• You are comfortable with some out-of-pocket costs in exchange for lower overall rates negotiated by the insurer.

• You like having the flexibility to see out-of-network providers if needed, even though costs will be higher.

• You want to choose from a selection of primary care doctors and specialists without needing referrals.

• You expect to use in-network providers for most of your healthcare needs.