What Are Preferred Provider Organization (PPO) Plans & How Do They Work?

An Easy Guide To PPO Plans

A preferred provider organization plan or PPO is an insurance policy that lets you see the doctor who accepts your insurance plan at a lower cost. It sounds great, right? Unfortunately, some plans can be confusing and even misleading.

Most health care providers require members to pay out of pocket before beginning treatment, but if you sign up for a PPO plan, your insurer pays those costs. The insured member gets billed directly from their insurer instead of paying out of pocket. 

That means you get access to a wider network of doctors and specialists. You also save significant amounts of money each year because insurers generally offer lower premiums for these types of providers. And since you don’t have to worry about how much you owe upfront, you can devote more time to other things.

So, how does a PPO plan work? Is it worth it if I want to get health insurance in South Dakota? Read on to learn more.

An Easy Guide To PPO Plans

Understanding The Concept Of PPO Plans

A PPO is a health insurance plan where medical providers offer their services at reduced rates to subscribers. These plans usually provide more freedom to see any medical specialty without referrals from primary care doctors.

Nonetheless, this freedom has a cost. PPO plans are more expensive than other plans, especially when checking deductibles and copays. 

What Is The Purpose Of PPO Plans?

PPO plans offer coverage to their subscribers for the medical care they get. Their purpose is to provide flexibility more than affordable healthcare. 

PPOs have a network of providers their subscribers can use to reduce costs. However, those receiving health care services outside that network still get coverage from the plan. 

How Does It Work?

With a Preferred Provider Organization Plan, the plan provider contracts with medical providers to build a specific healthcare network. Under this contract, the medical providers charge the PPO and their clients at a lower rate than they would bill someone out of that plan. 

A subscriber can access the network after signing up for the PPO. They can also see any doctor in the network. The only requirement is to follow the contract and contact doctors from the network according to the health insurance plan in South Dakota.

PPOs can make appointments directly with the doctor without getting referrals from primary care physicians. That’s one of their most important benefits and a good reason to consider PPOs.

PPO subscribers must pay a small copay after each medical visit. PPO plans also have an annual deductible that subscribers must consider when calculating costs. The deductibles are the amount subscribers pay out-of-pocket each year before the health insurance company fully covers their healthcare service. 

Subscribers usually get some coverage for out-of-network care too. In that case, the PPO provider covers some of the costs, but the subscriber must be responsible for paying more out-of-pocket costs than they normally would with in-network services.

For these services, there’s a “customary and reasonable” fee schedule to calculate the amount the insurer can cover. 

Not all healthcare plans offer out-of-network coverage to subscribers. While it’s true that PPOs are flexible and hence so popular, they are also more expensive for subscribers than other plans. 


A PPO is a good option for healthcare, but it is not the only one. 

Another option is a point of service or POS health plan. It is similar to a PPO because it focuses on flexibility and allows subscribers to get medical services outside the network. 

Similar to PPOs, POS plans have a network of providers that subscribers can visit. But, contrary to PPOs, POS subscribers must contact a primary care physician first. In other words, they must first visit the primary doctor before seeing a specialist. 

POS subscribers can also see out-of-network doctors, but this option is not as flexible as PPOs. That’s because many POS plans still demand a referral from a primary care doctor. 

Finding The Best Health Insurance Plan In South Dakota

Getting health insurance can be challenging and stressful if you live in South Dakota. You must consider many things, so it can be hard to plan your budget without the right guidance. At South Dakota Health Insurance, we are ready to help! Our skilled agents will gladly work with you to find the health insurance plan you really need. Contact us now for more information. 

South Dakota Health Insurance
5040 Saturn Dr,
Rapid City, SD 57703

Tel: 605-653-3824
Email: info@southdakotahealthinsurance.co