PPO access – a better option than the Marketplace? Sometimes, yes.

My clients are experiencing more and more frustration in Colorado when enrolled into Marketplace plans and their given HMO or EPO networks.  So I’m reminding Coloradoans that there are nationwide (unrestricted) PPO plans available to individuals and families; and they are available for enrollment at any time of the year – outside of the annual open enrollment period.

Note: federal subsidies (tax credits) cannot be applied to offset the premium costs of these off-Marketplace plans.

Subscribing to a health insurance plan using a Preferred Provider Organization (PPO) nationwide network generally offers several advantages compared to state-based networks under the Affordable Care Act (commonly known as Obamacare).

Here are some key advantages:

Nationwide Coverage: PPO networks typically have a wider network of healthcare providers across the
country, allowing you to access medical services in multiple states without out-of-network penalties or limitations. This can be beneficial if you frequently travel or reside in different states.

Greater Provider Choice: PPO networks often have a larger pool of participating providers, including doctors, hospitals, and specialists. This means you have more options to choose from when seeking medical care, and you can often visit specialists without referrals from a primary care physician.

Out-of-Network Coverage: PPO plans usually provide some level of coverage for out-of-network care.  While the coverage may be lower compared to in-network care, it still offers financial protection if you need to see a provider who is not part of the network.

Flexibility and Autonomy: PPO plans generally provide more flexibility and autonomy in managing your healthcare. You have the freedom to see any provider without requiring a referral, and you have more control over your healthcare decisions.

Access to Top Hospitals and Specialists: PPO networks often include renowned hospitals and specialists who may be at the forefront of medical advancements or specialized treatments. This can be particularly advantageous if you have complex medical needs or require specialized care.

For most of my clients who cannot qualify for a federal subsidy (tax credit), PPO plans are less expensive than Marketplace plans. PPO plans are qualifying plans, however, so the companies offering them will review an individual or family’s health history, which can be disqualifying for some people.

Marketplace plans cannot consider pre-existing conditions or health history so they are guaranteed to issue once applied for… this is the ACA’s greatest attribute notwithstanding the challenges to see physicians and specialists of your choice.

Trade-offs for those that are needing to find their own individual or family coverage.

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