Dive Brief:
- A growing number of marketplace PPO plans have dropped their caps on out-of-network expenses, leaving members vulnerable to unlimited medical billing, according to a new analysis by the Robert Wood Johnson Foundation.
- The move muddies the waters on exactly what makes a PPO, given they typically used to pay a portion of out-of-network expenses, as well as provide consumer protection by setting annual limits on what policyholders would have to contribute toward out-of-network expenses.
- In 2015, 14% of the silver-level PPO plans had no annual cap on out-of-network costs, while for 2016, 45% of the new silver PPO plans coming to the market have no annual cap for out-of-network costs, the analysis finds.
Dive Insight:
As RWJF researcher Katherine Hempstead puts it, "The average PPO for sale in 2016 is less comprehensive than what was called a PPO in 2015.”
The analysis states the PPO category is "not very specifically defined," so plans can vary substantially in the extent of coverage they offer for out-of-network providers, the level of cost sharing they require, and size of their provider network. It adds out-of-network coverage doesn't affect a plan’s actuarial value (AV), so carriers can adjust it without AV impact.
Kaiser Health News adds the Affordable Care Act does not set any limits on what insurers can charge consumers for out-of-network care, as it does for in-network care, so this is an area in which insurers are looking to gain revenue and enable lower premiums. Although some states have considered or enacted some relevant consumer protections, they are typically limited, Consumers’ Union told KHN.