PPO Plan

This week I’m going to talk a little bit about PPOs.

I work with many people that had had coverage with their employer. They had a PPO, then they had Cobra, and now they’re on their own regarding buying their health insurance.

Let’s get into the details of a PPO:

  • In Texas, there is not a PPO on the individual market.
  • As far as using the Marketplace:
    • Blue Cross has a POS, which, in my mind does stand for something else
      • it’s not a PPO, because there are out-of-network benefits, but you still need a referral.
        • So it’s just like an HMO:
          • you still need a referral to go on a network
          • and the deductible is around d $10,000
          • After the deductible, they pay 50%.
          • So basically, you have no in-network coverage unless you have a major catastrophic event.

Okay, so then what are your options?

  1. If you have an LLC, and you have one employee or a spouse (the other employee)
    • We can do a group plan that offers you a PPO option.
  1. If you have your own LLC, and you may not want to offer benefits to an employee, or maybe your spouse is not on the LLC:
    • this means you have to be a W2 employee.
    • there are some legalities to work through on this.
  1. The other option for getting a PPO is doing the self-employed plan.
    • As long as you have an LLC, you don’t have to even pay yourself.
    • Or if you are a 1099 equivalent employee (K1 form).
    • Example:
      1. Hairstylists, real estate agents, plumbers, electricians, insurance agents, and people who are licensed to hold a license, and could work for somebody, but they could work on their own because of that licensure.
    • We have two PPO options:
      1. Blue Cross Blue Shield PPO option
      2. PHCS PPO option.
  1. If you are a typical 10 99 employee:
    • Contract work etc.
    • You are eligible for these PPO plans,
    • You do need to be able to prove that you’re a 1099 employee.


    • So I know a lot of you have heard of some of these different companies like Avon, Mary, Kay, Amway, Rodan and Fields, doTERRA, etc.
    • They all have the ability for you to buy products from them, but you can enroll to be an associate or a partner, and you pay a small fee to be one of those associates.
    • So you have the potential to sell the products from your website.
    • And so basically, now you’ve become a self-employed person.
    • So even if you do that, and just buy products for yourself, let’s say you just love Avon.
    • And if you sign up to be an Avon associate, you get a discount on your products. And that’s all you do. Well, that counts as a 1099 employee.
    • That doesn’t mean you have to file it that way for your taxes.
    • You just have to be able to prove that you’re an associate.
    • So that could get you in the door on that self-employed plan.
  1. And then lastly, the other way to get a PPO plan is to an indemnity product.
    • Some indemnity products are not considered by major medical insurance, they are health insurance, but they are not major medical insurance.
    • And what that means is they’re transparent about what they pay for different procedures.
    • So you know, might be that they pay $150 for a doctor visit, so if you go to the doctor, and the bill is $200, they pay $150, you’ll get a bill from the doctor for $50.
    • If you go to the doctor and the bill is $120 and the plan is supposed to pay $150, they pay the doctor in full. And then you get the difference of $30 sent back to you.
    • Those plans are usually PPO plans, some are available that are through First Care.
    • You have to be careful with these because sometimes preexisting conditions come into play.
    • Ideally, those are great for healthy people or people who have low usage of health insurance

Lastly, when it comes to PPOs, beware of limited plans!

    • If you’re looking at a PPO plan, and they’re telling you it’s UnitedHealthcare – that’s a limited benefit plan.
    • There are only a few companies that are true PPOs – be sure to ask what they offer, and have an agent like myself, work with you to be sure you are getting the best plan for your situation.

If you have any questions or concerns please feel free to reach out to me.

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(512) 827-8117


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Austin, Texas

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