Florida PPO – Preferred Provider Organization

"You should definitely look into the HSA's - Health Savings Account.  These have excellent tax benefits in addition to comprehensive health coverage."

Preferred Provider Organizations (PPO)

PPO organizations are managed care programs where medical providers have a contractual agreement to provide services at a predetermined rate. These plans are typically characterized as having much larger networks than the HMO's and they do not require referrals to seek other medical services.  Although you are not required to get a referral with a PPO in Florida it is a good idea to get a  pre-certification from the insurer.  The pre-certification is not a guarantee of coverage but it keeps the health insurer in the loop, and speeds up the claims process. 

Florida PPO's give back some of the decision making capability you lose in an HMO.  You are not required to stay in network for services, but you will pay less if you do.  You do not need to get referrals or choose a primary care physician (PCP), simply look up a provider in their directory and call for your appointment.  The downside is that the increased selection of providers and added control will result in higher premiums.

You can control your premiums, to a certain extent, with the deductible you choose.  The deductible is that portion of your annual medical expenses that you are responsible for before the insurance company pays.  The higher the deductible the lower the premium.  Increasing your deductible transfers more risk (on the little things) to you, which brings down the premium. Deductibles are not only found in Florida preferred provider organizations but also in some Florida health maintenance organizations like Vista Health Plan. The best rates for PPO's in Florida are usually with Aetna, Blue Cross Blue Shield of Florida, Humana One, and Cigna.

Once you meet the deductible you are only responsible for the co-insurance.  You will typically see 80/20, 50/50, or 100/0.  This is where things get tricky.  You also need to find the co-insurance limit.  This is usually $2,500, $5,000, or $10,000.  Beware of plans that have a co-insurance limit greater than $10,000.  Now that you have your percentage (i.e. 80/20) and your co-insurance limit (i.e. $10,000) you can figure out that you will pay 20% of the next $10,000 in medical bills for the year.  Once you have met the deductible and the co-insurance, the plan will pay 100% up to the policy maximums for covered services for that calendar year.

Policy maximums vary from plan to plan.  You should look for a plan that covers at least $3-5 Million for lifetime.  Watch out for annual maximums and limited benefits, especially on prescriptions, hospitalization, outpatient services, and emergency room coverage. 

Florida PPO's are good choice when:

  • You can live with the deductible and enjoy lower premiums.
  • You are healthy and you only want coverage in case something "major" happens.
  • You are looking for coverage/protection for those unseen, unpredictable events over which we have no control, but should they happen, you would want to be able to get the best medical care possible.
  • You do not participate in activities that could put you at risk of injury (i.e. contact sports, mountain climbing).  A high deductible would mean that you would end up paying for most of it yourself.
  • You are self-employed and don't have the benefit of free or subsidized insurance from an employer.
  • Your employer offers insurance, but it is just too expensive to put your family or spouse on that plan.
  • You want a wide selection of providers either locally or nationwide and you want to be able to choose your own doctors and specialists (in or out of network).
  • If all of the above apply then you should seriously consider a Florida Health Savings Account.  In my opinion it is the best thing you could do...if you use it properly.  It can save you lots of money!

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