Managed care
In terms of using such a plan, unlike an HMO plan, which has a copayment cost share feature (a nominal payment generally paid at the time of service), a PPO generally does not have a copayment but offers a deductible and a coinsurance feature. The deductible must be paid in full before any benefits are provided. After the deductible is met, the coinsurance benefits apply. If the PPO plan is an 80% coinsurance plan with a $1,000 deductible, the patient pays 100% of the allowed provider fee up to $1,000. The insurer will pay 80% of the other fees, and the patient will pay the remaining 20%. Charges above the allowed amount are not payable by the patient or insurer but written off as a discount by the physician.
Deductible
A deductible should not be confused with a franchise. Where a deductible represents a part of the expense for which the insurer is not liable, the franchise is a pure threshold that, when exceeded, transfers liability for the "entire" expense to the insurer. For example, with a franchise of $20,000, a claim of $19,900 is borne entirely by the policy holder and a claim of $20,500 is borne entirely by the insurer.