- We compare all your options, including private plans with PPO networks: no referrals, broad national access and out-of-network benefits.
- Private plans are sold outside the ACA marketplace and are often medically underwritten.
- Underwritten plans consider your health profile when setting eligibility and price.
- Healthy applicants who qualify may pay significantly less than for guaranteed-issue plans.
- Pre-existing conditions may be limited, so we compare private and ACA options side by side.
What "private health insurance" means
In everyday use, private health insurance usually means coverage bought directly from an insurance company or through a broker, outside the ACA marketplace. Many of these plans are medically underwritten: the carrier reviews your health history when deciding whether to offer coverage and at what price.
Unlike guaranteed-issue plans, medically underwritten policies evaluate your health profile when determining eligibility and rates. If you qualify, you may have access to more competitive pricing and coverage options.
Why PPO networks matter
Many private plans are built around PPO networks. For most of our clients, the network matters as much as the price:
- No referrals. See in-network specialists directly, without going through a primary care doctor first.
- Broad and national access. PPO networks are typically larger than HMO or EPO networks, and many work across state lines, which helps if you travel, split time between states or have children away at college.
- Out-of-network benefits. Many PPO plans still pay part of the cost when you see a provider outside the network.
- Keep your doctors. Before you apply, we check your doctors, specialists and hospitals in the plan's PPO directory.
In many counties, marketplace plans are HMO or EPO plans with narrower networks. A private PPO plan can be the way to keep the doctors you already use.
Guaranteed-issue vs. medically underwritten
| Guaranteed-issue (ACA) | Medically underwritten (private) | |
|---|---|---|
| Who is accepted | Everyone during enrollment periods | Based on your health profile |
| How price is set | Age, location, tobacco; not health history | Health history is also considered |
| Healthy applicants | Pay the same as everyone their age | May pay significantly less |
| Pre-existing conditions | Covered | May be limited |
| Network type | Often HMO or EPO, depending on county | Often PPO |
| Income-based tax credits | May be available | Not available |
| When you can apply | Open enrollment or a qualifying event | Often year-round |
Who private plans tend to suit
- Healthy individuals and families who rarely use care beyond checkups.
- Self-employed professionals and business owners whose income is too high for marketplace tax credits.
- People who missed open enrollment and don't qualify for a special enrollment period.
Have a health condition but still prefer private coverage? See pre-existing conditions and private plans outside the ACA.
They may not be the right choice if you have significant ongoing health needs, are planning a pregnancy, or qualify for meaningful marketplace tax credits. In those cases a guaranteed-issue plan may be the better value, and we'll say so.
Important: Not every private plan is ACA-compliant. Some plans sold outside the marketplace, including medically underwritten plans, are not required to follow all ACA rules, so they may limit or exclude pre-existing conditions and may not cover every essential health benefit, such as maternity care. We review each plan's terms with you before you apply, and approval is never guaranteed.
Questions we help you ask
- Which conditions, if any, are limited or excluded, and for how long?
- Is the plan renewable, and can the price change based on future claims?
- Which PPO network does it use, is it national, and are my doctors in it?
- What are the annual and per-service benefit limits, if any?
General information only, not tax, legal or medical advice. Plan availability, benefits, networks and pricing vary by carrier, state, county and eligibility. COBRA information is general; see the U.S. Department of Labor for full rules.