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, 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.

This year, 14 percent of existing silver-level PPO plans had no annual ceiling on out of network care. When new plans coming to the market and the existing plans that are continuing are factored together, that percentage will double to 30 percent of silver-level PPOs with no out-of-network financial cap in 2016, the analysis finds. Silver level plans, which are the second-lowest cost plans, are the most commonly purchased in the marketplace.

Not having any maximum cap on those costs “is what you expect … in a plan that doesn’t offer out-of-network benefits,” said RWJF researcher Katherine Hempstead. “You’re paying a deductible and then some kind of co-insurance ad infinitum. The average PPO for sale in 2016 is less comprehensive than what was called a PPO in 2015.”

The trend stretches the definition of a PPO and could catch consumers unaware, especially because many mainly check premium and deductible costs when shopping. Additionally, information about out-of-network costs is often harder to find on insurance websites, generally requiring consumers to click through to a lengthy “summary of benefits.” The first page gives details of the plan’s deductible and out-of-pocket expenses, both in and out of network.

But consumers should take that step before they sign up, say advocates, to know what their potential exposure might be. They should especially check PPOs, which many people choose specifically because they cover some out-of-network costs, generally paying a portion of the bill after a patient meets an annual deductible.

“This trend [toward no annual cap in some PPOs] creates even greater risk for consumers going out of network,” said Betsy Imholtz with Consumers Union, the advocacy arm of the organization that produces Consumer Reports.

All of UnitedHealth’s plans in Arizona, for example, have no annual cap on out-of-network costs. This year, for the first time, neither do any of the PPOs offered by the Blue Cross Blue Shield plans in Illinois, Oklahoma and New Mexico. Plans offered through a partnership between insurer Aetna and the Northern Virginia hospital system Inova also have no maximum cap for out of network.

Insured consumers have long faced costly consequences for going out of network.

But those concerns have grown in recent years, especially among people who buy their own insurance because they don’t get it through their jobs. That’s partly because the federal health law changed the way insurers do business, including .

While that has helped consumers with pre-existing conditions, insurers have sought other ways to cut their costs in order to slow premium growth. To do that, many now offer plans with smaller networks of doctors and hospitals, which can make it more likely that a policyholder will see non-network providers, either on purpose or inadvertently. For example, a patient might go to an in-network hospital, but be treated by a non-contracted physician or lab service.

The resulting bills can run into thousands of dollars. And the providers can “balance bill” patients for the difference between what the insurer pays toward their care and their actual charges, which are generally far higher. That amount doesn’t count toward a plan’s annual deductible or annual out of network maximum, if it has one.

Vince Hess of Grandview, Missouri, racked up about $800 in costs related to surgery for a broken hand in 2013. Hess, an actuary, first checked that his surgeon was in network. He had the operation at an in-network surgical center, but only learned later when he was billed that the two anesthesiologists who assisted in the surgery were not.

“Everything added up pretty fast,” said Hess, 57, who said he should have been told that he might be treated by out of network physicians. “I … have read a thousand health insurance contracts. That’s the irony, that I got burned. I don’t know how the average person does it who is not as familiar.”

Insurers and policy experts say there are sound reasons to have networks – they’re one way to negotiate with large hospital systems to bring costs down. They can also be used to steer patients to doctors or hospital systems with higher quality ratings, better prices, or both.

“Members get the most out of their benefits by using in-network providers,” said Thomas Meier, vice president of market solutions for Health Care Service Corporation, which owns Blue Cross Blue Shield plans in five states, including Illinois.

This year, to slow premium growth, Meier said his company’s PPO plans switched from having out-of-network caps to not having them in three states – Illinois, New Mexico and Oklahoma – and setting the cap at three times the in-network maximum in Montana.

“We do have to look at ways we can keep those premiums as affordable as possible,” he said. “If we offer a significant amount of out-of-network coverage, then the premium will come up and won’t meet that goal.”

While consumers’ concerns about out-of-network costs predate the Affordable Care Act, the law does not set any limits on what insurers or medical providers can charge policyholders for out-of-network care. Some states have either considered or put in place some related consumer protections, but they are, for the most part, limited, according to Consumers’ Union.

The law does, however, cap what insurers can charge policyholders annually for in-network care.

For 2016, plans must limit out-of-pocket costs for policyholders, which include deductibles and copayments, to $6,850 for individual coverage or $13,700 for family plans. Additionally, the law says insurers must charge in-network copayments for emergency department services at non-network hospitals because patients in urgent situations often can’t choose where they go.

Many PPO plans still do include annual limits on what a consumer might have to pay toward non-network care. (Any balance bill amounts generally do not count toward those deductibles or annual caps.) Often, those maximums are set at amounts double the in-network limits, but can range far higher.

In Montana, the silver-level Blue Preferred Silver PPO 101 offered by Blue Cross Blue Shield for 2016 has an out-of-network cap three times the in-network rate: $26,000 for individuals and $52,800 for family coverage.

A bronze-level plan offered by Anthem next year in Indiana has an out-of-network maximum of $30,000 a person, or $60,000 for a family. In Pennsylvania, Independence Blue Cross offers a silver-level PPO that carries a $20,000 a person and $40,000 a year out-of-pocket cap for non-network care.

Nationally, the mean out-of-pocket cap for non-network care for an individual in silver-level PPO plans $16,700, the RWJ analysis finds.

While not an exact comparison, another study showed that workers with job-based insurance have a median annual out-of-pocket maximum for care obtained out of network of $6,000 for individuals and $12,000 for families, according to a recent survey of nearly 2,500 employers by benefits firm Mercer.

Policy experts and brokers acknowledge that the marketplace caps would stretch most people’s budgets, but note they provide some protection because a very serious illness or accident could result in medical bills well above those amounts in a given year.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

The plans, usually known as preferred provider organizations or PPOs, pay for a portion of the costs of out-of-network hospitals and physicians. They are the most common type offered by employers, and some consumers in the individual marketplaces find them more appealing than health maintenance organizations and other policies that pay only for medical facilities and doctors with whom they have contracts.

The price gap between PPOs and HMOs is growing in many places where both are offered. In Chicago, the least expensive silver PPO next year will cost $270 a month, $75 more than the least expensive silver HMO, and 27 percent more than the cheapest silver plan costs now. Meanwhile, the price of the least expensive silver HMO in Chicago is dropping by 12 percent.

In Salt Lake City, the premium for the only silver PPO is growing by 30 percent, nearly four times the increase for the least expensive HMO. In Philadelphia, the cheapest silver PPO will be $389, $113 more than the cheapest HMO. This year, Philadelphians wanting a silver open access plan had to pay just $66 more. As in many places, insurers also are selling different bronze, gold and platinum PPOs (the metals indicate how the insurer and patient divide the cost of care), but the cheapest plan in each tier in Philadelphia is an HMO.

In Houston, the only plans available through the federal exchange have closed networks. Blue Cross Blue Shield of Texas, which offered a PPO plan in Houston for 2015, cited rising costs as a reason it will not offer any open access plans next year. There is at least one PPO that consumers can purchase directly or through a broker, offered by the Memorial Hermann Health System, but it is not listed in the federal marketplace offerings so premium subsidies are not available.

“Everyone is up in arms,” said Jo Middleton, a Houston insurance broker. “I do not have a single client who is happy. They want PPOs and can’t get them. They want the flexibility.”

The biggest complaint, she said, is not that the HMOs don’t allow out-of-network coverage, but that their networks are too small.

“If you are someone who needs several doctors and several specialists, it’s difficult to find a network they are all in,” Middleton said. “In many cases, the doctors may be in a network, but only have admitting privileges at a non-network hospital. In the 11 years I’ve been in the business, this is unprecedented.”

None of the plans available through the federal exchange in Houston include the city’s well-known MD Anderson Cancer Center in their networks. “It’s a huge problem,” said insurance broker J. Casey Lowery. “If you’re a cancer patient, think about it. All of a sudden you have to switch doctors.  Or, if you want to stay with a doctor because he saved your life, and now you’re in an HMO, you have no coverage.”

Dan Fontaine, an administrator at MD Anderson, said some insurers did not invite the cancer center into their network. Others offered payment rates that he said “we don’t consider serious” because they were too low “and oftentimes less than what Medicare or Medicaid pay us.” He said the center was trying to make arrangements with insurers for patients who are in treatment now.

Plans with out-of-network benefits are not disappearing everywhere. Alaska, Arkansas and Wyoming are bucking the trend by only offering PPOs. Out-of-network costs even with PPOs can be prohibitively expensive since many PPOs will only cover a minority of costs, diminishing the difference from HMOs. Also, people who qualify for government premium subsidies can be insulated from the full cost of a PPO.

Allen Gjersvig, an executive at the Arizona Alliance for Community Health Centers, says one PPO in the state requires approval before seeing a specialist—a restriction often associated with HMOs—while there are HMOs that don’t mandate pre-approval of specialist visits. “The meaningfulness of HMO and PPO is starting to really blur,” he said.

Brokers say they are scrambling to help customers find new plans.

“I’m 31 and hardly go to the doctor,” said broker Michael Ledgerwood, president of the Houston Association of Health Underwriters. “If my doctor isn’t in the network, I don’t care. But my response would be quite different if I had more health care issues or saw more specialists.”

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).