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Medicare Advantage PPO Plans

Summary: Medicare Advantage PPO plans are a more flexible type of Medicare Advantage plan. Medicare PPO plans allow you to go to an out-of-network healthcare provider without paying the full cost of the service out-of-pocket. We review what a Medicare Advantage PPO plan is, what benefits are included, and how you can enroll in a PPO plan if it fits your needs. Estimated Read Time: 6 mins

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Table of Contents:

  1. What is a Medicare Advantage PPO Plan?
  2. How Do PPO Plans Work?
  3. Medicare Advantage PPO vs. Original Medicare
  4. What are the Benefits of a PPO Plan?
  5. What is the Best Medicare Advantage PPO Plan?
  6. Who Can Enroll in a Medicare Advantage PPO Plan?
  7. Get More Information on Medicare PPO Plans

Medicare Advantage PPO plans are a popular type of Medicare Advantage plan that allows you the freedom to receive care from doctors outside of your plan’s network without needing to pay the full cost of coverage out-of-pocket.

Medicare Advantage PPO plans are offered by private insurance companies which means each plan can come with different costs and features. However, the goal of a PPO plan remains the same, to provide flexibility in managing your healthcare coverage. However, it is essential to note that this option may come at a higher cost than some alternatives.

What is a Medicare Advantage PPO Plan?

PPO stands for Preferred Provider Organization in healthcare. A Medicare PPO plan is a type of Medicare Advantage plan that allows you to use healthcare providers that are both in and outside of your network.

Medicare Advantage PPO allows you to receive care from any doctor or facility regardless of your plans network. This means, if you enroll in a PPO Medicare Advantage plan you won’t be limited to a specific provider network, and you won’t need a referral to see a specialist.

Because Medicare PPO plans are available through private insurance companies, the costs, out-of-pocket maximums, and available plan types will vary depending on the insurance company, plan, and service area.

How Do PPO Plans Work?

Medicare Advantage PPO plans give you more flexibility in receiving care than Medicare Advantage HMO plans. With a PPO plan, you can get some coverage for out-of-network healthcare services. This is in contrast to an HMO plan, where you can only get a portion of coverage for healthcare providers outside of your plan’s network in an emergency.

When you use doctors and facilities within your Medicare Advantage plan’s network, you’ll pay less than you will for services outside of your plan’s network. If you go to a doctor outside of your plan’s network, your Medicare Advantage PPO plan will still pay a portion of the costs, but you will likely need to pay more out-of-pocket to cover them. Nevertheless, both are viable options.

Each Medicare PPO plan has an out-of-pocket maximum in place to cap your out-of-pocket costs. The carrier sets a specific dollar amount as the most you can spend out of your own pocket for health care through your plan during a calendar year. Once you reach the out-of-pocket maximum, the Medicare PPO plan picks up 100% of your healthcare costs. It’s important to note that premiums and Part D cost sharing don’t apply towards your out-of-pocket maximum. However, deductibles, copays, and coinsurance do.

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Medicare Advantage PPO vs. Original Medicare

Medicare Advantage PPO plans must cover the same types of services as Original Medicare. However, the main difference between the two is that the government administers Original Medicare, while Medicare Advantage plans are available through private insurance companies. This means that the premiums and out-of-pocket costs for Medicare Advantage PPO plans may vary. It’s important to note that you still have to pay the Part B premium while you’re enrolled in a Medicare Advantage PPO plan.

Also, unlike Medicare PPO Advantage plans, Original Medicare does not have provider networks. You can see any health care provider you want, as long as they accept  Medicare.

Furthermore, when you enroll in Original Medicare, you can also sign up for a Medicare Supplement plan to help cover out-of-pocket costs. However, you cannot enroll in a Medicare Supplement (Medigap) plan at the same time you have a Medicare Advantage plan – including a Medicare Advantage PPO.

What are the Benefits of a PPO Plan?

One major reason for picking a Medicare PPO plan is the flexibility. Sure, you’ll have to pay more when receiving healthcare services outside of your network, but at least you have the option to see out-of-network providers unlike other Medicare Advantage plans.

You also have all of the same inpatient benefits of Medicare Part A and outpatient benefits of Medicare Part B. You may even have lower monthly premiums or additional benefits not included with Original Medicare, depending on the plan.

What is the Best Medicare Advantage PPO Plan?

Every Medicare beneficiary has different coverage needs so it’s hard to determine a one-size-fits-all “best” Medicare Advantage plan. Remember, all Medicare Advantage plans are available through private companies. Thus, policy benefit guidelines and prices vary.

No singular plan can be universally accepted as the best option for everyone.

Instead, you should evaluate your healthcare needs to identify which Medicare Advantage PPO plan will be the best fit for you. Speaking with a licensed insurance agent is a great way to ensure you receive the best coverage for your healthcare and budget needs.

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Who Can Enroll in a Medicare Advantage PPO Plan?

To join a Medicare Advantage PPO plan, you must first be enrolled in Original Medicare  (Medicare Part A and Part B). If you are enrolling in a Medicare Advantage plan for the first time, you can do so during your Initial Enrollment Period.

If you have previously enrolled in Original Medicare and are looking to switch to a Medicare Advantage PPO plan, you can do so during the Annual Enrollment Period every year from October 15 through December 7. But if you don’t switch during the Annual Enrollment Period, additional opportunities are available.

If you’re looking to switch to a Medicare Advantage PPO plan from an HMO plan you can do so during the Medicare Advantage Open Enrollment Period from January 1 until March 31. However, this enrollment period is only for those that already have a Medicare Advantage plan beforehand.

Remember that if you are outside any of these enrollment periods, you may not change your plan unless you qualify for a Special Enrollment Period. To qualify for a Special Enrollment Period, you’ll need to have a qualifying life event occur, such as moving, losing your coverage, or a change in your Medicare coverage.

Get More Information on Medicare PPO Plans

Healthcare costs are rising, so it is more important than ever to find the right Medicare plan. MedicareFAQ can help by researching the rates for top insurance companies in your area and helping you find the right coverage for your needs.

Call us at the number above or fill out our form to start the comparison process.

Sources

MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.

  1. Preferred Provider Organizations, Medicare. Accessed March 2022.
    https://www.medicare.gov/health-drug-plans/health-plans/your-coverage-options/PPO
Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare guru serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Medicare Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

5 thoughts on "Medicare Advantage PPO Plans"

  1. I have humanachoiceppo. If I choose a dental who does not accept Humana can I get reimbursed? If yes, what is the turn around time for reimbursement and what forms do I need to file?

    1. Justine, reimbursement is on a case-by-case basis. You would need to complete the form and send it to Humana. However, there is no set time frame to hear back about their decision.

  2. Hi Linda! First off, I’m so sorry to hear about the passing of your mother. Medicare Advantage plans do have copays & coinsurance. Without seeing the bills, it would be hard to say for sure, but it seems like the bills coming from UHC are probably the coinsurance and/or copays left over after the Advantage plan paid their portion of your mothers’ medical costs for services received not related to hospice care. That’s one of the biggest disadvantages of Medicare Advantage plans, they choose how much of each service they want to cover. Original Medicare is not responsible for paying any medical bills that were not directly connected to her hospice care. Original Medicare is responsible for all her hospice care bills. UHC is responsible for THEIR portion of your mothers’ medical bills NOT associated with hospice. Then, your mother is responsible for any copays and/or coinsurance that fall under the Advantage plan for services NOT associated with hospice. I hope this helps!

  3. How is a medicare health plan with prescription drug coverage different from a medicare supplemental ins?

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