2016 PPO Plans Remove Out-Of-Network Cost Limits, A Costly Trap For Consumers

by Julie Appleby; Kaiser Health News
Published in The Lund Report, December 4, 2015

Citing the flexibility they offer, many consumers choose health plans that provide some coverage outside the insurer’s network. Traditionally, such plans not only paid a portion of the bill, but also set an annual cap on how much policy holders paid toward out-of-network care.

Not anymore.

An increasing number of preferred provider plans (PPOs) offered under the federal health law have no ceiling at all for out-of-network costs, leaving policyholders facing unlimited financial exposure, similar to what more restrictive and often less expensive types of coverage, such as health maintenance organizations (HMOs), offer.

Forty-five percent of the silver-level PPO plans coming to the market for the first time in 2016 provide no annual cap for policyholders’ out-of-network costs, an analysis by the Robert Wood Johnson Foundation finds. Not having a cap could lead to tens of thousands of dollars in bills for patients who are hospitalized or treated by providers who are not part of the plan’s network.