A reported asked me about the availability of PPO plans on Healthcare.gov recently. I had to do some data digging as this was not something that I’ve been tracking too diligently. PPO plans are not unusual but they are not common.
Insurers can offer four basic plan types; HMO, POS, EPO and PPO. The plan types vary on whether or not there is an out of network benefit of any sort and whether or not there is a primary care provider gatekeeping function from higher cost care. HMOs are the most restrictive plan types. They have no out of network benefit and a gatekeeping function. PPO plans are the least restrictive as there is an out of network benefit and no gatekeeping.
All else being equal (network, insurer, risk adjustment etc) the least restrictive plan will tend to have higher premiums than more restrictive plans. There is a ton of variance as there is a lot of fuzziness between what an HMO is as implemented and what an EPO is. There is a lot of fuzzines between a POS and a PPO. Some times the only difference is what license the insurer has to sell a product and the label designation has no pricing impact. But as a rule of thumb, more restrictive plans are lower premium plans and therefore more attractive to individuals who think that they are going to have low costs throughout the year.
Since 2018, PPO plans have become rarer on Healthcare.gov. In 2018, Iowa, Tennessee and Kansas had PPO plans offered throughout the state. In 2019 to present, these states have no PPO plans. HMO plans are more common. POS plans have no notable change as they are overwhelming a Mississippi watershed choice. EPO plans look to be slighlty more comon with more of Texas and all of Tennessee have EPOs in 2021 compared to 2018.
Insurers have a lot of latitude in what they offer. The trend seems to be a movement away from less restrictive and towards more restrictive plans types.
Below the fold is the Tableau presentation: