Guides / Private PPO
Private major medical PPO plans.
These plans share the cost of covered care through a PPO network. You answer health questions, and the price is based on your health. A healthy applicant may pay less than they would on the Marketplace. That is a maybe, not a promise.
Who is a private PPO for?
This option fits people who want the plan to share the cost of covered care, and who are ready to answer health questions so the price can reflect their health.
Network, deductible, maximum
- You use a PPO network. Doctors and hospitals in that network are the ones the plan is built around. Out of network care may cost more, or it may not be covered. Check the provider search, then call the office. Provider search
- You meet a deductible, then share costs, up to an out-of-pocket maximum the plan sets. Those numbers are in the brochure.
- Covered care is shared. Office visits, hospital care, and other covered services follow the schedule in the brochure, up to the maximum the plan sets.
- You can usually apply in any month. The carrier sets the start date. Coverage starts when the carrier issues the policy.
Health questions and price
- The carrier reads the health questions. It can accept you, offer a higher rate, or decline you. A conversation with Seth is not an approval.
- A healthy applicant may pay less than on the Marketplace. That follows from medical underwriting. It is not a quote, and it is not true for every person.
- It is not an ACA plan. Benefits, limits, and exclusions are in the brochure. Need an ACA plan or Medicare? We can help with that too.
- Another private option is a fixed indemnity plan. That one pays a set cash benefit. Fixed indemnity plans.
What does an ERISA health plan mean?
These plans fall under ERISA, a federal law that governs employer-style benefit plans, so they follow federal rules rather than Marketplace rules.
- They are employer-style plans. People sometimes describe that as self-funded. They are not state-regulated individual ACA plans.
- The plan documents control. Benefits and the steps for a question about a claim are in the documents for the plan you are shown. Seth can walk through them on a call.
How is private PPO pricing set?
The price is based on your health. A healthy applicant may pay less than they would on the Marketplace. That is not a promise.
- Healthy applicants may pay less than they would on the Marketplace. That follows from medical underwriting. It is not a quote, and it is not true for every person or every plan.
- This page does not promise savings. The carrier sets the final premium when it reviews the application. A number Seth quotes is not the final premium.
- Approval depends on the health questions. Read each question, including the time frame, and answer it yourself. If an answer is yes, or you are not sure, stop and book a call before you submit. Seth will not tell you how to answer.
- Plans can look back at recent care. How that applies to you is a question for Seth.
- If this plan is not the fit, other options exist. A fixed indemnity plan is one of them. The Marketplace is another. We can help with an ACA plan too. Need Medicare? We can help with that too.
Use the which-fits worksheet to put your own premium next to an out-of-pocket maximum. Seth can walk through which setup matches your situation.
Plan name and brochure
Questions about your own coverage go to Seth. This page cannot answer them.