Thursday, October 04, 2018

An Unspoken ObamaCare Shanda: Bye, Bye PPO

As we mentioned a few weeks ago, Anthem is diving back into the individual major medical market for Open Enrollment '19; although there's no official word yet on product details, it's a safe bet that they'll be using the ubiquitous (and problematic) HMO model. And we've just recently learned that Medical Mutual is also re-joining the Ohio market, and they've confirmed that theirs is, indeed, an HMO product.

So what's the big deal, Henry? Shouldn't you be grateful that (at least) two more options will exist for your fellow Buckeyes? And isn't this incentive enough to dive back in yourself?

If only it were that simple. Yes, I suppose it's gratifying to see carriers dipping their toes back into the individual medical pool. But it's disheartening - if completely understandable - that all of the choices available for the upcoming season are HMO's, with zero PPO options even available.

Ok, but you still haven't answered the question: So. What?

Back in the day, the PPO (Preferred Provider Organization) was dominant: under this model, one got the "biggest bang for the buck" by accessing care in-network, but there was always this safety net, or out-of-pocket cap, on non-network services. Sure, it stung a little more, but at least one wasn't footing the entire bill.

Under the HMO model, there is essentially zero coverage for non-life-threatening situations outside of the (now even narrower) network. This means that unless one is basically bleeding out on the front steps of the out-of-network facility, there's likely to be no coverage.

This is a major issue for folks with significant and/or chronic health issues: what if your oncologist isn't in your plan's network? Yeah, a problem. And it's a direct result of ObamaCare rules which leave carriers with few options to rein in costs. Of course I'm not holding them entirely blameless, but this is really the only rational choice.

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