The health insurance marketplace established by the Affordable Care Act (ACA) offers consumers a range of plan options from various insurance carriers. One common question is whether preferred provider organization (PPO) plans are available on the marketplace.
The short answer is yes – PPOs are one of the plan types offered through the insurance marketplace. However, specifics can vary by state and region.
What is a PPO Health Plan?
Before diving into PPO availability on the marketplace, let’s first understand what a PPO plan entails.
PPO health insurance is a type of plan that offers flexibility in choosing healthcare providers. Here are some key features:
Nationwide networks – PPOs allow members to see any doctor or hospital in their plan’s national network, even out-of-state.
Out-of-network coverage – PPOs will pay for services from non-network providers as well, albeit at a higher cost to the member.
No referrals needed – You can see any specialist without needing a referral from a primary care physician.
Cost sharing – Members pay a portion of the bill via copays, deductibles and coinsurance. Costs are lower when using in-network providers.
PPO plans offer convenience and flexibility compared to options like HMOs. However, this freedom costs more in monthly premiums. PPOs typically fall on the higher end of the premium spectrum.
Are PPO Plans Offered on the Marketplace?
When the Affordable Care Act marketplace launched in 2014, PPO plans were scarce on the exchanges. Limited provider networks like HMOs dominated at first.
Over time, insurers expanded offerings to include preferred provider plans. Today, PPOs are widely available on the marketplace across metal tiers.
Nationwide, about one-third of marketplace plan selections are PPOs based on federal data. Availability varies significantly by state and region however.
Some key facts about PPOs on the marketplace:
Offered by major insurers – Large carriers like UnitedHealthcare, Anthem Blue Cross Blue Shield, Cigna and Aetna offer PPO options on exchanges.
All metal tiers – Marketplace PPO plans are sold at bronze, silver, gold and platinum levels. High premium platinum plans are more likely to be PPOs.
Mix of local and national networks – Some PPOs offer regional provider networks while others have broad nationwide networks. Check provider directories when comparing plans.
Check for out-of-state coverage – Not all PPO marketplace plans cover out-of-state providers. Confirm coverage details if you travel frequently.
Higher premiums – On average, marketplace PPOs cost $80-100 more in monthly premiums than HMOs per federal data.
Shoppers on the exchanges can filter and compare PPO policies along with other plan types. Metal tier, monthly premium, deductible and provider network are key factors to weigh.
Why Choose a Marketplace PPO Plan?
PPOs appeal to shoppers who value flexible coverage with more provider choice. Here are some of the potential benefits of selecting a marketplace PPO:
Freedom to choose providers – See any doctor or hospital in the PPO network without needing referrals for specialists. Some plans offer nationwide coverage.
Out-of-network coverage – PPOs cover non-network providers, unlike more restrictive HMO and EPO plans (except emergencies).
Travel coverage – Marketplace PPOs with national networks or out-of-state coverage allow you to see providers across the country.
No primary care physician (PCP) – You don’t need to choose or get referrals from a designated PCP. See any network specialist you choose.
Familiar providers – If you have physicians you want to keep seeing, you can likely find a PPO plan that includes them in-network.
Access to major hospitals and clinics – PPO networks are generally broader than HMO networks and include prominent healthcare systems.
Brand recognition – Major insurers like United, Anthem and Cigna offer PPO options on the marketplace.
For shoppers who prioritize choice and flexibility when selecting healthcare, a marketplace PPO plan may be the optimal choice despite the higher monthly premium.
What are the Drawbacks of Marketplace PPO Plans?
While PPOs offer more freedom than restrictive HMO networks, they also come with some potential disadvantages to consider:
Higher premiums – The nationwide networks and out-of-network coverage increase premium costs. Marketplace PPOs average $80-100 more per month than HMO plans.
Deductibles may be higher – With their lower premiums, bronze and silver marketplace PPOs often have deductibles over $5000+. Make sure you can afford out-of-pocket costs.
No integrated care – Unlike closed HMO systems, PPO coverage is less coordinated across providers. There’s no central medical record.
Prior authorizations may be required – Some PPO plans require prior approval for certain services, like MRIs or specialist visits. HMOs don’t have this requirement.
Provider billing issues – Because PPO networks are broader, billing and reimbursement issues between providers and the insurer occur more frequently.
For some shoppers, the freedom and flexibility isn’t worth the higher costs and administrative hassles. Make sure to analyze your situation.
Who Might Want to Avoid a Marketplace PPO?
While marketplace PPOs offer attractive benefits like provider choice, they aren’t the optimal choice for every consumer.
Individuals who may want to consider other plan types beyond PPOs include:
Those who qualify for cost-sharing reductions by buying silver plans. PPOs have higher premiums that reduce subsidy savings.
Healthy individuals who don’t need frequent specialty care or nationwide coverage. HMOs provide sufficient access at lower costs.
People who prefer integrated care coordination from a single healthcare system. PPOs lack this benefit.
Those who want to minimize premiums and don’t care about specific providers or facilities. Shop for lowest cost plans.
Families with incomes under 250% of federal poverty level. Cost-sharing subsidies on silver plans outweigh PPO flexibility.
People living in regions with limited marketplace PPO options that lack national networks.
For many subsidy-eligible shoppers, silver HMO plans make financial sense despite their network restrictions. Evaluate all plan types during open enrollment.
Tips for Choosing a Marketplace PPO Plan
If you’ve weighed the pros and cons and decide a PPO meets your coverage needs and budget, here are some tips for picking a plan on the marketplace:
Use the marketplace plan preview tool to filter and compare PPO policies first.
Check that your existing doctors and hospitals are in-network using the plan’s provider directory.
For frequent travelers, look for nationwide networks or out-of-state coverage.
Balance monthly premium costs against the plan deductible and out-of-pocket maximum. Don’t overpay.
Weigh platinum versus gold tiers for lower deductibles if you use healthcare frequently.
Review exclusions and prior authorization rules that may impact coverage access and costs.
Consider adding a dental plan separately if the medical PPO lacks this benefit.
Doing your homework is key to finding the optimal marketplace PPO policy for your healthcare needs and budget.
PPOs provide attractive flexibility and access compared to restrictive HMO networks. However, the broader coverage comes with trade-offs like higher monthly premiums.
Carefully balancing provider choice against costs allows marketplace shoppers to determine if a PPO plan or a different plan type makes most financial sense. Comparing all available medical plan options is key to making an informed coverage selection.
How to Pick the Right Marketplace Insurance Plan: HSA, HDHP vs PPO & More!
Is Marketplace health insurance the same as Obamacare?
What is the highest income to qualify for Obamacare?
Typical max. income
What’s HMO vs PPO?