ACA question

[kbear]

I was looking at the ACA plans to get an idea of cost. All I could find was HMO plans, am I missing something or not looking in the right place?  As someone who has worked in healthcare for 22 years, this is a huge red flag and very concerning. Has anyone been able to get a PPO through the ACA? I'm hoping that it's because I've been looking during the wrong time of year.

[rantk81]

The number and types of plans offered is dependent on your zip code.  Each area has a different list of ACA exchange plans.  It's crappy that all of the choices in your area are HMO plans.  All of the ACA exchange plans in my area have small networks and don't include the area's best hospitals.  Some of my choices are PPO though... but have astronomical out-of-network deductibles.

For example, one of the "more economical" PPO plans on my list for the ACA exchange has the following:

Deductible (for out of network):
Individual $15,000
Family $45,000

Out of Pocket Maximum (for out of network):
Individual Unlimited
Family Unlimited


So essentially, even though they call it a "PPO" plan, it's worthless because there's no cap on spending, and you're paying for everything out of pocket anyway.  At that rate, might as well stick to a HMO/smaller-network.

[bmjohnson35]

It varies based on your zip code and can change annually.  We will have to switch to HMO when we switch to ACA next year.  Our previous residence was in a different county and it had PPO's available.  Unfortunately, the ACA is our only option due to pre-existing conditions.  Aside from the subsidies available through the ACA, coverage of pre-existing conditions is the most important element of the ACA for us.

BJ

[kbear]

Thanks for taking the time to respond.  Definitely a shock/surprise to find this out, but at least I now know.
rantk81 - that's  deductible is ridiculous, what the heck!!.

[geekette]

Yeah, if you need/insist on going out of network, your deductible and OOP max can be nuts. 

Per Healthcare.gov, the max out of pocket (not just the deductible) for a Marketplace plan in 2020 is $8,200 for an individual plan and $16,400 for a family plan.  Those limits are lowered, depending on income, for Silver plans.  Our plan just has copays for medical visits and Rx, so we never hit our deductible, but our OOP costs aren't very high.

What's the problem with an HMO?  We used to have a Kaiser HMO plan years ago, and really liked it.  Unfortunately, they pulled out of our area.

[RWTL]

We plan on traveling once we retire, so choosing a domicile state is flexible.  Some Florida zip codes we've checked have access to PPO plans.

Getting access to a PPO will be essential for a full time traveler.

[jpdx]

As others have explained, your options depend on which insurers offer plans in your area -- technically this is not based on your zip code, but rather your county. More populated counties tend to have more options and wider networks than rural counties. Also, states with the political motivation to make this system work tend to have more options.

From my personal experience, I can tell you in Multnomah county, Oregon there are a half-dozen insurers offering PPO plans. For four years I've gone with a Gold PPO plan with a large, state-wide network which includes a nearby highly-rated research hospital. Deductible is $1000 (or as low as $100 with CSR).