How private PPO health plans work

What a private plan is

A private health plan is coverage you buy directly from an insurance company, outside the government Marketplace. Instead of being priced on your household income, it is priced on your age and health.

That is why private plans often appeal to generally healthy people who earn too much for Marketplace tax credits. If you are healthy, your price can reflect that.

What "PPO" means

PPO stands for preferred provider organization. In plain terms, it is a network of doctors and hospitals that agreed to lower prices with the plan.

• You can usually see doctors in the network without a referral.
• Many private plans use large national PPO networks, which helps if you travel or split time between states.
• Seeing a doctor outside the network usually costs more, or may not be covered.

Before you choose a plan, your agent can check whether your doctors are in its network.

How the price is set

When you apply for a private plan, you answer health questions. The insurance company uses your answers, your age and where you live to set your price.

Two things follow from that:

• Healthy applicants often pay less than they would for an unsubsidized Marketplace plan.
• Not everyone is approved, and some health conditions can be excluded or raise the price.

What to check before you apply

Private plans vary a lot. Some cover a wide range of care. Others pay set amounts for certain services. A good agent walks you through:

• What is covered, and what is not
• How pre-existing conditions are handled
• Deductibles, copays and any yearly limits
• Whether your doctors and prescriptions are covered
• How and when you can renew

Read the plan details before you sign. If anything is unclear, ask.

Who it fits, and who it does not

Often a good fit: generally healthy people, the self-employed, 1099 workers and families who pay full price and want a PPO network. It also helps if you need coverage to start soon, since many private plans start any month.

Often not the best fit: people with ongoing health conditions, or households whose income qualifies for large Marketplace tax credits. In those cases a Marketplace plan is usually the better choice, and your agent should tell you so.