8/21/2025
What is a PPO?
A PPO (Preferred Provider Organization) offers far more flexibility:
- No Referrals Needed – See any specialist directly.
- Nationwide Network – Access providers across state lines.
- Out-of-Network Benefits – You still have coverage, though at a higher cost.
With a National PPO, you have freedom to choose your providers anywhere in the country.
Why This Matters for Marketplace Plans
Most ACA Marketplace plans are HMOs or EPOs with very limited networks. That means:
- Traveling out of state? No coverage for routine care.
- Want the top specialist in another city? Likely out-of-network.
- Live near a state border? Your options could be even more limited.
Real-Life Scenarios
- The Frequent Traveler – A self-employed consultant in New York visits clients in Florida, Texas, and California. His HMO only covers him in NY, leaving him at risk.
- The Specialist Search – A woman with a rare condition finds the best doctor in another state. Her HMO won’t cover the visit; a National PPO would.
- The College Student – Parents in one state, student in another. An HMO leaves the student without local care options.
Cost Comparison
While PPOs often have slightly higher premiums, they can save thousands by avoiding out-of-network bills and providing nationwide access.
Example:
- HMO Premium: $550/month with $7,500 deductible, no out-of-network coverage.
- PPO Premium: $625/month with $2,500 deductible, nationwide access.
Who Benefits Most from a National PPO
- Self-employed professionals
- Frequent travelers
- Families with kids in college out of state
- People with rare or complex health conditions
Final Thought: Choosing between a National PPO and a Marketplace HMO isn’t just a financial decision—it’s about your freedom to choose the care you need, where you need it. If flexibility matters to you, a PPO could be worth every penny.
Want to compare your current plan to a National PPO? Call (716) 503-1113 for a free coverage review.