Charts In-Network vs. Out-of-Network Costs Comparison Related Topics Cost-Sharing Plan Characteristics and Types

Preferred provider organizations (PPOs) generally offer a wider choice of providers than HMOs. Premiums may be similar to or slightly higher than HMOs, and out-of-pocket costs are generally higher and more complicated than those for HMOs. PPOs allow participants to venture out of the provider network at their discretion and do not require a referral from a primary care physician. However, straying from the PPO network means that participants may pay a greater share of the costs.

Many PPOs available to California small businesses reimburse 60 percent of out-of-network costs and 80 percent of in-network costs (with the employee responsible for the remaining 40 percent or 20 percent). These percentages may be applied to full charges (“sticker” prices), discounted fees that the health plan has negotiated with providers (“negotiated fees”), or regional average fees (“allowable” or “usual and customary” amounts). Keep in mind that this example is one of many possibilities—in-network and out-of-network coverage can differ from plan to plan.

Other documents in the Coverage Types section:

• Alternatives to Offering Group Coverage
• Group Coverage
• Health Maintenance Organizations (HMOs)
• Health Savings Accounts (HSAs)
• Individual Coverage
• Plan Characteristics and Types
• Point-of-Service Plan (POS)
• Preferred Provider Organizations (PPOs)
• Public or Subsidized Health Insurance
• Tiered Hospital Benefits
• Health Reimbursement Arrangements
• Plans Offered Under the Health Insurance Exchanges