If you're buying your own health insurance, you'll usually end up choosing between an ACA Marketplace plan and a private PPO plan. They work differently, and the right one depends on your health, your income, and the doctors you want to keep.
The short version
- ACA Marketplace plans accept everyone, cover a standard set of benefits, and can come with premium help based on your income.
- Private PPO plans are sold by carriers and agents, often have broader networks and lower out-of-pocket costs, and can be approved or declined based on your health.
Side by side
| ACA Marketplace | Private PPO | |
|---|---|---|
| Health questions | None. Can't be turned down or charged more for health history. | Yes. Medically underwritten, so you can be approved, charged more, limited or declined. |
| Premium help | Depends on your income and household | Not based on income, and no Marketplace premium help |
| Benefits | A standard set of essential benefits | Varies. Not required to cover everything Marketplace plans must. |
| Existing conditions | Covered | May be limited or excluded |
| Doctors | Network varies by plan | Often broader PPO networks |
| Deductible | Depends on plan | Some options with no deductible |
| When you can enroll | Open enrollment, or a special enrollment period | Not tied to open enrollment in the same way |
Who a Marketplace plan tends to fit
- People with ongoing health needs or conditions they need covered
- People whose income qualifies them for premium help
- Anyone who'd be turned down or excluded by a private plan's health questions
Who a private PPO plan tends to fit
- Generally healthy people who want broader doctor choice
- People whose income is too high for much premium help
- People who missed open enrollment and need coverage sooner
- Anyone who wants a lower deductible and is willing to answer health questions
What to watch for
Some private plans aren't ACA-compliant, which means they aren't required to cover pre-existing conditions, maternity, mental health, or other benefits that Marketplace plans must. That's not automatically bad, but you should know exactly what's excluded before you buy. Ask for the list in writing and read it.
Also be honest on the health questions. A mistake there can cause a claim to be denied later.
Where we come in
We're an independent agency, so we're not limited to one carrier. We put both kinds of plans side by side with your real numbers and tell you which we'd pick if it were our money. Compare options on our quote form, or reach out.
This article is general information, not a guarantee of coverage or pricing. Plan availability, benefits, and eligibility vary by state and individual. Some private plans are medically underwritten and do not include all ACA essential health benefits.